Utilization Review Lead

Job Description: RN - Utilization Review Lead

Position Title: RN - Utilization Review Lead

Location: Anacortes, WA

Department/Unit: Utilization Review

Shift: 8 Hour Variable

Job Purpose

The Utilization Review RN, Lead is responsible for the oversight, planning, direction, and coordination of Utilization Review (UR) services within the Care Management Department. Reporting to the ACU/CM Manager, this role ensures compliance with all CMS regulations and supports effective utilization of resources throughout the healthcare continuum.

Key Responsibilities

Leadership Duties:

• Provide support, education, and guidance for other UR RNs and direction for Social Workers.
• Lead multidisciplinary rounds as directed by the ACU/CM Manager.
  
  

Core Responsibilities

• Review medical records to determine and document medical necessity for inpatient and observation status using established criteria.
• Identify issues and variations in utilization, escalating concerns to appropriate healthcare team members.
• Actively support initiatives that promote effective resource use.
• Develop and coordinate discharge plans in collaboration with the healthcare team, incorporating patient priorities.
• Identify patients at risk for post-hospitalization problems and collaborate with Social Services for appropriate referrals.
• Advocate for necessary services and funding to meet care plan goals.
• Arrange appropriate community services while adhering to state and federal health regulations.
• Monitor patients' conditions and responsiveness to interventions.
• Communicate effectively with patients, staff, other departments, and providers to ensure needs are met.
• Foster professional relationships with managers, physicians, and hospital staff.
• Utilize effective communication and conflict resolution skills to support the team in addressing difficult interactions.
• Accept delegated responsibilities from the ACU/CM Manager.
  
  

Additional Duties

• Manage utilization management, clinical coordination, palliative care, and discharge planning for assigned patient areas.
• Collaborate with Emergency Department (ED) physicians and staff to determine appropriate admission levels and support social admissions as necessary.
• Assist the ACU/CM Manager in managing daily/monthly budget performance and productivity.
• Support medical records and patient accounts with chart and charge capture reviews as directed.
• Lead daily multidisciplinary care rounds to ensure safe discharge plans, delegating as needed.
• Work collaboratively with departments in reviewing coding, utilization, and discharge issues.
• Maintain positive relationships with post-hospitalization care organizations and ensure compliance with external requirements.
• Prioritize patients based on intensity, need, and required follow-up; assist in developing support systems.
• Collaborate with healthcare team members and insurance case managers to facilitate care and optimize outcomes.
• Ensure appropriate documentation of utilization management data and review Clinical Documentation Specialist reports.
• Review clinical appeals with UR Physician or third-party Physician Advisor to address documentation issues.
• Maintain positive interdepartmental relationships and serve as a role model for the team.
• Facilitate orientation processes for new staff members and assist in developing staffing plans as needed.
• Assist in establishing departmental onboarding processes, competency evaluations, and collaboration with Nurse Educator.
  
  

Qualifications

• Current Registered Nurse (RN) license in the state of Washington.
• Bachelor’s degree in Nursing preferred; equivalent experience may be considered.
• Minimum of [insert years] years of experience in Utilization Review or related field.
• Strong understanding of CMS regulations and compliance standards.
• Excellent communication, leadership, and interpersonal skills.
  
  

Benefits

• Competitive salary based on experience.
• Comprehensive benefits package including health insurance, retirement plans, and paid time off.
  
  

Why Join Us? At EliteCare Medical Staffing, we value passion for providing high-quality care. We offer a supportive environment where you can grow professionally. If you are ready to make a difference in patients' lives and advance your career, we encourage you to apply!

Application Process: Interested candidates should submit their resume and a cover letter outlining their qualifications and interest in the position to [Insert Application Email/Link].

Skills: rnp,nursing education,utilization review,communication