UM Team Lead-Onsite

About the role

At Wellstar, our mission is simple, yet powerful: to enhance the health and well-being of every person we serve. We are proud to have become a shining example of what's possible when the brightest professionals dedicate themselves to making a difference in the healthcare industry, and in people's lives.

Responsibilities

• Disposition Planning
  • Collaborate with Discharge Planner and provide resource information in an appropriate and efficient manner.
  • Identify and document barriers for timely disposition.
  • Collaborate with other members of the healthcare team in planning care appropriate for medical needs.
  • Understand eligibility processes and criteria for both private and public, local, state, and federal resources.
  • Respond to referrals from hospital staff, physician offices, community, and family to provide resource information, counseling, and education to the community.
  • Allow for any cultural or religious beliefs in providing service and continuity of care.
  • Partner with the patient and significant others using appropriate methods (e.g., interdisciplinary rounds) to keep them updated and make the patient’s goals the focus of the plan of care.
• Exemplary Practice and Outcomes
  • Participate in the development of protocols and procedures to achieve best practice outcomes (e.g., decrease in re-admission rates, avoidable days, adverse events).
• Resources and Support Utilization Management
  • Initiate assessment for necessity and appropriateness of health services using established screening criteria (e.g., MCG, Interqual).
  • Assess insurance and coverage issues such as managed care, PPO, HMO, and identify preferred providers.
  • Identify issues relating to patient type and/or appropriateness of admission and collaborate with physician/physician advisor for resolution.
  • Timely identification and referral for alternative level of care.
  • Responsible for timely and accurate certification of hospital admission and provide required information to payors.
  • Monitor and evaluate patient/clients’ ongoing plan of care and facilitate modification using established screening criteria.
  • Serve as the Subject Matter Expert (SME) for Utilization Review, MCG, and WQ management in Epic.
  • Assist in training and orientation of new staff members and manage the daily work schedule for staff.
  • Monitor and evaluate the appropriateness of managed care denials and collaborate with attending physician, managed care representative, and Medical Director.
  • Monitor compliance with Medicare/Medicaid regulations (e.g., order for patient type for billing, appropriate billing).
  • Evaluate and negotiate patient needs based on quality, cost, and necessity.
  • Participate in performance improvement activities inclusive of all stakeholders, research, and research utilization to promote safe, quality patient care.
• Team Leader Responsibilities
  • Coach, mentor, and serve as a resource to the Centralized UM team on workflow and clinical expertise.
  • Participate in the interviewing process with Directors & Manager for potential team members.
  • Lead QA & PI activities for the team.
  • Provide guidance and education during the orientation process to ensure new team members understand Centralized UM functions.
  • Provide input for yearly performance evaluations for team members.
  • Assist with ongoing training on new initiatives for the department along with resource manager and directors.
  • Serve as a preceptor and/or mentor for other professionals and/or students to ensure a current and future qualified workforce.
• Professional Development and Initiative Documentation
  • Ensure all records are up-to-date and legible.
  • Complete all Epic UR software screens.
  • Ensure timely and accurate documentation of clinical reviews and insurance updates as required by payors.
  • Participate in data collection, pose relevant clinical questions to advance evidence-based practice, consult appropriate experts, and use evidence to address practice questions.
  • Perform other duties as assigned.
  • Comply with all Wellstar Health System policies, standards of work, and code of conduct.

Requirements

• Education
  • Associate Nursing or Diploma (Nurse) or Bachelor’s Nursing (Preferred).
• Licenses and Certifications
  • BLS - Basic Life Support or ARC-BLS - American Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor.
  • RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact.
  • All certifications are required upon hire unless otherwise stated.
• Experience
  • Minimum 3 years of Clinical Practice/Experience required.
  • Minimum 1 year with one to two years of Case Management/Care Coordination experience.
• Skills
  • Knowledge of Case Management process.
  • Excellent organizational and professional communication skills.
  • Knowledgeable in utilizing screening criteria in review of clinical data with respect to patients/clients’ needs for healthcare.
  • Ability to effect change, perform critical analysis, promote client/family autonomy, and plan and organize effectively for the continuum of care.