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    Lead, Inpatient Um Nurse Capped

    Medpoint Management
    0-5 years
    $93,000 to $95,000 per year
    Remote, USA
    10 July 18, 2024
    Job Description
    Job Type: Full Time Education: B.Sc./ M.Sc./ M.Pharm/ B.Pharm/ Life Sciences Skills: Causality Assessment, Clinical SAS Programming, Communication Skills, GCP guidelines, ICD-10 CM Codes, CPT-Codes, HCPCS Codes, ICD-10 CM, CPT, HCPCS Coding, ICH guidelines, ICSR Case Processing, Interpersonal Skill, Labelling Assessment, MedDRA Coding, Medical Billing, Medical Coding, Medical Terminology, Narrative Writing, Research & Development, Technical Skill, Triage of ICSRs, WHO DD Coding

     

    Summary

    The role of Inpatient Utilization Management (UM) Team Leader involves providing leadership, training, and support to the Inpatient UM team. This position focuses on ensuring high-quality, cost-effective care by conducting utilization management reviews during high-volume situations, ensuring patients receive medically necessary care to achieve optimal medical outcomes.

    Duties and Responsibilities

    • Team Leadership and Support

      • Provide leadership, direction, and ongoing training to the Inpatient UM team, both local and remote.
      • Conduct performance evaluations, provide feedback, and conduct necessary staff trainings.
      • Assist in developing and updating departmental policies, procedures, workflows, and SOPs as required.

    • Clinical Review and Oversight

      • Lead the clinical review process for the assigned team and remote staff, ensuring adherence to regulatory requirements and organizational policies.
      • Monitor daily workload and assess staffing needs to maintain productivity standards.
      • Escalate issues identified during rounds to the Inpatient UM Supervisor for resolution.

    • Collaboration and Coordination

      • Coordinate team meetings and facilitate team-building exercises.
      • Collaborate with other departments to resolve authorization issues and support UM staff with member grievances.
      • Lead daily huddles with hospitalists and Medical Directors for outlier cases.

    • Quality Assurance and Compliance

      • Review denial verbiage to ensure accuracy before submission for processing.
      • Provide oversight of Denial Explanations of Non-Coverage (DENCs) and Notices of Medicare Non-Coverage (NOMNCs) to ensure compliance.

    • Patient Care Coordination

      • Assist nurses in identifying eligible cases for referral to various internal and external programs.
      • Ensure seamless transition of care by collaborating with Case Management, Behavioral Health, and other support services.

    • Operational Support

      • Monitor and evaluate team performance metrics to identify improvement opportunities and set realistic goals.
      • Provide coverage for vacation relief and manage modified work assignments during absences.

    Minimum Job Requirements

    • Proficiency in MPM databases and utilization of data fields/logic by the team.
    • Current RN or LVN licensure; BSN preferred.
    • Knowledge of case management, utilization review, discharge planning, and reimbursement structures.

    Skills and Abilities

    • Strong organizational and communication skills, capable of effectively relaying information to diverse stakeholders.
    • Ability to analyze data and identify errors or key assumptions, facilitating efficient decision-making.
    • Proven leadership skills with the ability to mentor and coach team members to achieve goals effectively.

    This structured format emphasizes the responsibilities, qualifications, and skills required for the Inpatient UM Team Leader role, providing a clear overview for prospective candidates.

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