Job Summary: The Utilization Review Clinical Review (CR) 3 Team Lead will assist the Director of UR and Associate Director of UR with daily staff mentoring, leadership, and resource provision. This position will have supervisory oversight of the CR level II nurses. This position utilizes first-level screening criteria daily and accurately identifies patients who do not meet the severity of illness and/or intensity of service for admission and continued stay at the time of medical record screening. Responds to Managed Care/Insurance Company inquiries regarding admission, concurrent and discharge reviews within one business day and/or time frame per negotiated contract, to prevent payment denials. Participates in interdisciplinary rounds on a regular basis to assist with the identification of level of care changes, opportunities for educating the team regarding regulatory and quality issues, and issues related to the facilitation of discharge planning. Attends and participates in staff meetings and submits items for agendas when needed. Cross trains to behavioral health and STAR reviews. Assists with orientation of new staff. Assists with quality metric analysis for KPI reporting and actively participates and provides input for committees. Other duties as assigned.
Minimum Qualifications: NYS Licensed/Registered (or eligible) RN, Bachelors Degree in Nursing and a minimum of three years RN nursing experience OR Associates Degree in Nursing and five years RN nursing experience required. A minimum of 2 years of UR experience with progressive proficiency and autonomy of reviews is required. Previous leadership experience is required. Must possess comprehensive and broad knowledge of complex clinical and medical concepts and demonstrate overall proficiency in clinical conceptual understanding for purposes of the level of care review. Strong communication skills, both written and verbal, as well as interpersonal skills required for interface and collaboration with leadership, colleagues, providers, Physician Advisors, regulatory agencies, and other health care-related entities required. Strong organizational skills with the ability to manage assignments and responsibilities in hybrid work setting mostly independent, communicating a need for additional support or guidance when necessary. Proficiency in technology use, including PC, Windows, Microsoft applications, Zoom/WebEx platforms, etc. Demonstrated strong interpersonal communication skills. Proficiency with current CMS regulations as well as level of care criteria.
Preferred Qualifications: Three or more years of progressive experience in a UR department with a track record of orienting new staff, peer mentoring and progression of autonomous work.
Work Days: Monday - Friday 8-4:30 some weekends required
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