Lead, Inpatient UM Nurse

Summary

Provides leadership, support, training, and direction to the Inpatient UM teammates. The incumbent will use clinical judgment to provide utilization management review for inpatient during high volume situations. Provide high quality, cost-effective care to enable patients to achieve maximum medical improvement, while receiving care deemed medically necessary.

Duties and Responsibilities

· Conducts review of the TMs timecard (T&A)

· Conducts 30-days, 60-days, 90-days, 6-month, and annual performance evaluations for assigned UM TM’s.

· Provides performance feedback to the UM staff and conducts staff trainings as needed.

· Provides leadership, direction, training, and support to the assigned team and remote Inpatient UM staff.

· Assists in the development and updates department Policies and Procedures, Workflows, and SOP’s as needed.

· Assists in the refinement/improvement of the UM programs. Participates in continuous process improvement endeavors

· Assists in organizing and coordinating Team Meetings.

· Plans team building exercises.

· Reinforces MPM Policies and provides Corrective Action Plans to staff when needed

· Evaluates appropriateness of care through interpretation of benefits as outlined in Title 22, Medi-Cal Provider Manual, DMHC and/or CMS regulatory requirements, and IPA policies and procedures for each product line.

· Elicits medical information from providers and medical records and applies clinical judgment to determine medical necessity and provides timely reports/authorizations for recommended treatment.

Minimum Job Requirements

· Current RN or LVN licensure; Preferred: BSN level of education.

· Registered Nurse or Licensed Vocational Nurse with clinically focused work history.

· Prefer three-five years clinical experience within an acute health care setting with recent work history in acute care case management role or related health care experience.

· Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of Milliman or other clinical decision support criteria, discharge planning, and reimbursement structures (i.e. Government and non-governmental payers).

Skill and Abilities

· Excellent notetaker with the ability to relay large amount of information in a digestible format.

· Ability to efficiently scrub data to understand errors and/ or key assumptions.

· Ability to pursue issues proactively with forward thinking.