Nurse Utilization Review Supervisor

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The University of Miami has a great opportunity for a Nurse Utilization Review Supervisor to work at UTower.

POSITION SUMMARY:

This position functions as the Supervisor for the Case Management Department under the direction of the Director of Case Management, supervision is Case Manager Manager. This position analyzes and distributes daily assignments, oversight of staff and assure compliance with case manager and/or utilization review initiatives. The supervisor will assume the oversight of the direct reports assigned; this position will provide input and complete annual evaluations and have input regarding employee discipline, human resource related issues etc. with oversight by Case Management Manager. Person in this position will be available to assist Care Coordination staff when experiencing family/physician issues and attempt to resolve such issues.

In addition to the above administrative responsibilities, the supervisor may be responsible for functioning as a Case Manager and/or Utilization Review Nurse as well with a decreased patient load based on census and departmental staffing needs. This position will assist the manager and/or director with physician, patient and family issues, multidisciplinary treatment team, escalate to Managed Care plans, and when indicated, legal representative(s) when warranted. Rounding on assigned floors to assure facilitation of services, timely delivery of clinical and community services to patients and families through effective utilization of available resources. Manage observation patient process, assist with and assure appropriate placement, oversee medical necessity review completions utilizing the contracted licensed medical necessity criteria software. Proactively works with physician(s) regarding medical necessity and care coordination related to discharge planning needs of the patient. Facilitates decision making in establishing an evaluation program, an interdisciplinary treatment plan, and an assessment of the patient's status and need for provision of continuing care.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Utilization Management/Continuum of Care:

Reviews hospital EMR census, completes and forwards daily assignment to all staff as appropriate, distributes to nursing supervisors. Oversight of Outpatient Observation cases to assure patients have active discharge vs appropriateness of Inpatient services based on medical necessity, CMS two-midnight rule and/or Interqual® criteria. Assures compliance of admission reviews utilizing InterQual® criteria on all new cases within twenty-four (24) hours of admission, occasionally assists staff with completion of reviews; assures compliance and conducts continued stay case reviews when necessary. Conducts audits to ensure admission appropriateness, clinical necessity, and timeliness of ancillary services.

Collaborates with the attending physician when warranted based on escalation.

Collaborates with the manager, director and the physician advisor on difficult cases, outliers, and resource intense cases. Reviews and discusses case with the Physician Advisor (PA) after the Case Manager has made every attempt to work with the attending physician. All cases presented to the PA will be clearly outlined, with problems identified and alternative solutions for each problem.

Participates in the development, implementation, and evaluation of the continuum of care:

Facilitate patient access, assessing patient needs, ensuring that patients are smoothly transitioned from one care setting to the next, providing information to patients, families, and other providers who are receiving patient, disseminating case management, utilization management activities to appropriate members of the health care team, documenting treatment plan, discharge plan and family/guardian discussions in appropriate place in the medical record. Establishes monitoring protocols to assure compliance with department initiatives and CMS requirements and maintains effective working relationship with representatives of managed care plans when warranted.

Notifies Manager and/or Director of Case Management concurrently of any potential

and/or actual denials:

Oversight of denials during weekends, review and resolve if patient classification issue vs. arrangement of peer-to-peer process (P2P).

Assures initiation of HINN letter per CMS guidelines by case manager when appeal is upheld by QIO. Assists management with maintaining and continually updating information regarding JCAHO Standards, Regulations of OSHA and AHCA and other regulatory agencies.

Discharge Planning/Continuum of Care

Assist the manager of social services when needed to facilitate timely and appropriate discharge by coordinating discharge plans with appropriate departments (Home Health, and Managed Care Plans) and arranging for any interagency referrals or transportation needs.

Assures coordination of discharge planning with the patient and family to allow for a safe, smooth discharge to home or other care facility. Assists with escalating coordination delays with patient's Managed Care Plan. Participates in the weekly complex case review meetings and is an active participant when applicable. Assures any delays are documented as Avoidable Days. Monitors and ensures compliance with Discharge Important Message from Medicare, a CMS requirement. Monitors and assures compliance with case manager documentation for Outpatient/Observation and Inpatient admissions.

Serves as an educational resource to Medical and Facility Staff

Educates, coordinates, and provides information to members of the multidisciplinary healthcare team who can assist and/or improve discharge planning when knowledge deficit identified; Enhances professional growth and development through participation in educational programs, current literature, in-service education, conferences, seminars, and workshops when needed.

Serves as preceptor to new Case Managers

Oversight of case managers on orientation to assure compliance with all job duties. Provides in-service on various aspects of utilization management as requested to weekend staff.

Complies with all policies & procedures that pertain to HIPAA including the minimum necessary requirements for this position; As a part of the requirements for this position, the employee has access to the entire medical record for the purpose of reviewing appropriate coordinating care and planning for discharge needs and arrangements.

Limits the protected health information (PHI) disclosed or requested to the amount reasonably necessary to achieve the purpose of the request. The disclosures or requests that occur on a routine basis include: patient demographics, condition, notification of actual/potential victim of abuse or neglect, description of injuries for the purposes of a crime investigation, actual/potential for organ donation, & patient disposition updates.

DIRECTION/SUPERVISION OF OTHERS

This position requires the individual to be able to perform job duties responsibly with little supervision. The Supervisor works closely with the entire Case Management Department. The direct report is to the Director of Case Management, supervision will be Case Manager Manager.

CORE QUALIFICATIONS

Education:

Bachelor’s degree in relevant field required

Certification and Licensing:

Valid State of Florida RN license required

Refer to department description for applicable certification requirements

Experience:

Minimum 2 years of relevant experience required

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.

Job Status:

Full time

Employee Type:

Staff