Under the supervision of the Utilization Review Manager, serves as the Team Leader to the Utilization Review staff. Has the overall accountability for the utilization management. Collaborates with other members of the health care team to identify appropriate utilization of resources and to ensure reimbursement. Utilizes InterQual criteria and Dragonfly care level scores as a guideline to confirm medical necessity reviews.

1. Serves as team leader for the day to day operations for the Utilization Review Function, providing feedback and direction to staff.

• Overseeing auditing for third party payers.
• Assist in orientation, improvement performance, disciplinary action, and time/attendance.

1. Functions as a consultant to utilization review and staff for solving challenging utilization issues, denials, and appeals through the DCH System.
2. Assist in denial management.
3. Educates the UR team members and care management team in InterQual, Jiva, and Dragonfly.
4. Monitors the utilization of Commercial observation services.
5. Informs staff of any insurance changes involving InterQual guidelines, Dragonfly, or in providing clinical reviews.
6. Refers cases to the appropriate Physician Advisor due to medical necessity, quality, or delay in service.
7. Monitors patient’s clinical course to verify patient’s continued need for acute hospital level of care.
8. Negotiates a resolution of any disagreement over the need for acute hospital level of care with the insurer.
9. Collaborates with appropriate parties regarding inappropriate admissions, delays in services or discharge, and the over-utilization of hospital resources.
10. Maintains records in a complete, detailed, and orderly manner.
11. Identifies potentially avoidable days per department policy.
12. Educates staff and physicians about managed care principles, observation status, discharge planning, and reimbursement rules.
13. Evaluates medical records for appropriateness of admission status utilizing a combination of clinical information, screening criteria, and third party information. Collaborates with the business office as needed.
14. Collaborates with all members of the multidisciplinary team to facilitate the utilization review and case management process.
15. Supports and participates in department strategies and efforts focused on improving clinical documentation by physicians and staff.
16. Conducts special focus reviews as directed.
17. Supports departmental operations to ensure consistency with health system/department policies.
18. As a member of the utilization review practice:

• Seeks and provides peer consultation about cases that are presenting problems and/or experiencing significant deviation from the plan of care.
• Participates in quality improvement and evaluation processes related to the case management practice.

20. Demonstrates the knowledge and skills necessary to provide care appropriate to the age of patients served.
21. Follows Case Management policy regarding Utilization Review process.
22. Adheres to DCH Health System facility and department policies and procedures as well as standards from external regulatory agencies and accrediting bodies (i.e., JCAHO, Department of Public Health, QIO, etc...)
23. Participates in activities of professional associations as appropriate.
24. Participates and assists in departmental studies and projects as assigned.
25. Performs basic administrative tasks related to the job, including but not limited to, preparing reports and statistical record keeping.
26. Maintains confidentiality of all information.
27. Attends mandatory in-service programs.
28. Responsible to support and participate in department strategies and efforts
    focused on improving length of stay (LOS).
29. Is knowledgeable of hospital mission, vision, and values and performs in a manner that supports them.
30. Identifies and reports Quality and Risk Management concerns.

1. Secures appropriate status orders from physicians and documents in medical record.
2. Maintains confidentiality at all times related to both patient and employee information.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

Registered Nurse licensed in the State of Alabama.  BSN degree preferred

Minimum of 5 years of clinical experience, predominantly in the acute care setting.

Experience in case management, discharge planning, or utilization review within hospital, insurance, or workers’ compensation settings preferred.

Ability to establish priorities, meet deadlines, and maintain proper productivity.

Ability to form positive, collaborative relationships with hospital staff, patients, families, and post-acute providers.

Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge.

Ability to effectively negotiate with internal and external providers of patient care services.

Ability to develop leadership skills and to serve as a role model for clinical staff.

Ability to lead and actively participate in multidisciplinary teams.

Basic computer skills.

Ability to work independently or within a team structure.

Excellent interpersonal skills and communication style.

Must be able to read, write legibly, speak, and comprehend English. 

WORKING CONDITIONS

WORK CONTEXT

• Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
• Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance.
• Ability to encourage and build mutual trust, respect, and cooperation among team members.
• Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
• Ability to work independently or within a team structure.
• May be exposed to environmental cleaning chemicals.

PHYSICAL FACTORS

• Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects. If the use of arm and/or leg controls requires exertion of forces greater than that for sedentary work and the worker sits most of the time, the job is rated for light work.
• Ability to tolerate prolonged periods of sitting or standing and/or walking.
• Ability to reach reasonable distances to handle equipment.
• Good manual and finger dexterity.
• Must be able to perform the duties with or without reasonable accommodation.
• Hearing and vision must be normal or corrected to within normal range.
• Physical presence onsite is essential.