RN Clinical Leader- Utilization Review
The Utilization Review Clinical Leader meets the responsibilities and competencies of the Utilization Review Nurse role. The Utilization Review Clinical Leader works closely with the Utilization Management Program Manager to coordinate the UR functions within the Care Coordination Department. They will also serve as a contact for the appeal process for inpatient clinical denials.
The Utilization Review Clinical Leader will serve as a liason to the UR Specialists and will oversee the orientation of newly hired UR Specialists. The UR Clinical Leader will assign delegates and communicate assignments effectively to ensure proper optimal utilization of resources. They will collaborate with the Utilization Management Program Manager to maximize financial reimbursement by assisting as needed with facilitating the appeals of denied days. This individual is responsible for coordination with the Utilization Review Specialist Staff to assure that all admission and continued stay reviews are completed with appropriate hospital approved medical necessity applied.
The Utilization Review Clinical Leader will demonstrate a high level of expertise with standardized criteria the institution is using and be able to educate others in its use. They will also maintain a level of expertise in denials and assist the UM Program Manager in denial management as needed.
The Utilization Review Clinical Leader will serve as the professional liason to the UM Program Manager as well as serve in the capacity of a UR Specialist.
Why Nationwide Children's Hospital?
The moment you walk through our doors, you can feel it. When you meet one of our patient families, you believe it. And when you talk with anyone who works here, you want to be part of it, too. Welcome to Nationwide Children's Hospital, where Passion Meets Purpose.
Here, Everyone Matters. We're 12,000 strong. And it takes every single one of us to improve the lives of the kids we care for, and the kids from around the world we'll never even meet.Kids who are living healthier, fuller lives because of the knowledge we share. We know it takesaCollaborative Cultureto deliver on our promise to provide the very best, innovative care and to fosternewdiscoveries, made possible by the most groundbreaking research. Anywhere.
Ask anyone with a Nationwide Children's badge what they do for a living. They'll tell you it's More Than a Job. It's a calling. It's achanceto use and grow your talent to make an impact thattrulymatters.Because here, we exist simply to help children everywhere.
Nationwide Children's Hospital. A Place to Be Proud
1. Assists with maintaining departmental staffing needs in accordance with budget and established ratios including use of contingent personnel.
2. Participates in the recruitment, evaluation, and hiring of Utilization Review Specialist staff in collaboration with the UM Program Manager.
3. Ensures appropriate orientation, training, competence, professional growth and development of staff to ensure consistency in performance.
4. Contributes to the development of self and utilization review specialist staff through identification of learning needs, development of continuing education and serving as a role model, preceptor and mentor.
5. Evaluates staff performance and competency via written performance appraisals and corrective action feedback in collaboration with the UM Program Manager.
6. Participates in ongoing education related to information technology for the department which includes off site nurseries
7. Demonstrates competency in computer applications role modeling EPIC and Allscripts documentation.
8. Participates in collection, analysis and use of data for quality and process improvement.
9. Recognizes and responds to variances that increase length of stay or have risk management implications. Reports findings to the UM Program Manager for action and resolution.
10. Remains up to date on regulatory and compliance issues (CMS, Joint Commission) and provides education and updates to UR Specialist staff and others about changes and requirements.
11. Facilitates and enlists staff participation in Patient Care Services and Hospital activities such as policy/procedure review, infection control activities or safety and quality activities.
12. Provides assistance to and coverage for the UM Program Manager.
13. Collaborates with Care Coordination leadership team in program development.
14. Communicates clearly and effectively to others.
15. Supports evidence based practice through participation in research, patient safety, quality improvement activities and special projects.
16. Fully participates in maintaining a positive team environment that is conducive to customer satisfaction. Builds trust among co-workers, focusing on accomplishing hospital and departmental mission and goals. Develops and maintains rapport with others. Listens well.
KNOWLEDGE, SKILLS AND ABILITIES REQUIRED
1. Bachelor's Degree in Nursing
2. Licensure: Licensed as a Registered Nurse in the State of Ohio.
3. Pediatric or Case Management certification desirable.
4. Five years of nursing experience. At least one year in pediatric nursing is highly preferred. Nursing experience may include inpatient nursing, care coordination, utilization review, discharge planning, community health nursing.
5. Effective customer service, communication, negotiation, and interpersonal relationship skills required. Persuades or influences others through spoken or written communication.
6. High level of initiative, self-direction and accountability for actions required.
MINIMUM PHYSICAL REQUIREMENTS
Must be able to see, hear, speak, read and perform manual tasks with or without accommodation and care for oneself, with little or no difficulty. Performance of principal duties and responsibilities may require ability to travel.
The above list of duties is intended to describe the general nature and level of work performed by individuals assigned to this classification. It is not to be construed as an exhaustive list of duties performed by the individual so classified, nor is it intended to limit or modify the right of any supervisor to assign, direct, and control the work of employees under his/her supervision.
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