RN, Registered Nurse Utilization Review Lead - Behavioral Medicine - Full Time in Alamogordo, NM

Summary:

The Registered Nurse Utilization Review Lead will be the initial point of contact for the health plans utilization management team regarding any questions, issues, or concerns. The RN Utilization Review Lead effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services. They critically think for appropriateness of care provided to the patients and competently utilize approved screening criteria. The RN Utilization Review Lead is responsible for hands-on leadership of the Utilization Management Nursing Team to contain medical costs, oversee the utilization of health services and treatments, and ensuring the UM team meets designated quality metrics. The Lead serves as a clinical resource to the utilization management team, members, and outside medical providers.

Responsibilities:

• Frequently communicates complex information and interacts through electronic documentation tools.
• Oversees the provision of Utilization Management functions which include Pre-Certification, Concurrent Review, as well as Discharge Planning for Admissions and Outpatient Services.
• Continuously evaluates workflow issues while seeking to improve processes that impact the Department.
• Supervises, analyzes and coordinates the daily activities of the work queue to ensure that departmental productivity goals are met with regards to quality, timeliness, accuracy and consistency of medical decisions. Drives performance of teams while promoting inter-rater reliability.
• Recommends and implements department policies and procedures, and interfaces with other areas to ensure consistent applications.
• Develops and monitors goals for staff as well as provides ongoing feedback and coaching.
• Conducts performance reviews on an annual basis, coaches for performance, and leads by example.
• Supervises the daily operational duties of a care team. Ensures an atmosphere within the team, which fosters open communication, teamwork, ownership and empowerment to make decisions. 
• Other duties as assigned

Requirements:

Licenses, Registrations, or Certifications

• RN License in state of employment or compact required
• CPR certification preferred
• Certification in Case Management preferred

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time