RN Utilization Review Supervisor - FT Days

Northeast Georgia Medical Center; United States; On-site; USD 90,000 - 130,000; Full time

Job summary

Northeast Georgia Health System seeks a Nursing - Registered Nurse to supervise the Utilization Review Department, ensuring effective clinical utilization reviews, precertification, denial analysis, and related revenue activities. Collaboration with Case Management and Revenue Cycle leaders supports safe patient care and compliant service delivery.

Ideal candidates will have an RN license in GA, an Associate degree, and UR/Case Management experience, plus strong communication and leadership

Qualifications

• GA RN license (current)
• Associate degree required
• Experience in Utilization Management or Case Management; knowledge of healthcare regulations

Responsibilities

• Supervise day-to-day UR operations including precertification and reviews
• Serve as clinical resource for UR policies and government programs
• Develop/update UR policies to improve reimbursement and care quality
• Recruit, onboard and train UR staff; monitor performance against KPIs
• Collaborate with Case Management and other departments to ensure seamless care and compliance

Skills

Communication

Supervisory experience

Organizational skills

Attention to detail

Education

Associate degree

Bachelor's degree (preferred)

Tools

MS Office

Excel

Word

Job description

Job Category

Nursing - Registered Nurse

Work Shift/Schedule

8 Hr Morning - Afternoon

Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.

About the Role

Job Summary

Supervises the day-to-day operations of the Utilization Review Department to ensure effective and efficient clinical utilization review services are delivered related to medical necessity reviews, precertification, denial analysis, and other revenue related activities. Promotes cooperation with Utilization Review standards by the medical staff. Works collaboratively with Case Management and Revenue Cycle leaders to support the efforts around delivery of safe patient care and compliant delivery of services while promoting a safe environment at NGHS.

Minimum Job Qualifications

• Licensure or other certifications: Commensurate with professional requirements, successful completion of CCM exam, and currently GA licensed RN.
• Educational Requirements: Associates Degree.
• Minimum Experience: Experience in at least one (1) major component of Utilization Management or Case Management. Experience working with third party payers and Physicians. Experience and knowledge in healthcare Federal and State regulations is required.
• Other:

Preferred Job Qualifications

• Preferred Licensure or other certifications:
• Preferred Educational Requirements: Bachelors Degree Nursing, Business Health, Management, etc.
• Preferred Experience: Previous leadership and/or supervisory experience. Experience of the Utilization Review area within a mid-large hospital (200+ beds) or five (5) or more years experience in hospital clinical/financial operations and management.
• Other:

Job Specific and Unique Knowledge, Skills and Abilities

• Excellent written and verbal communication skills with the ability to communicate effectively and diplomatically with multi-disciplinary team.
• Supervisory or managerial experience including hiring, training, coaching, and counseling of employees.
• Experience in developing processes, standard workflows, procedures, and policies that positively impact efficient utilization review standards and reimbursement.
• Strong computer skills with the ability to use Microsoft Office, including, but not limited to Microsoft Excel and Word; be able to create spreadsheets, review/sort data, create formulas and word processing.
• Working knowledge of criteria for Medicare, Medicaid, HMO and private insurance coverage; knowledgeable of Federal and State regulations and hospital finance.
• Knowledgeable of Utilization Review principles and Case Management models, along with principles of quality assurance/improvement.
• Must be detail-oriented, able to work independently and possess strong organizational skills with the ability to prioritize multiple issues, tasks and projects while meeting defined timeframes.

Essential Tasks and Responsibilities

• Provides supervision of the day-to-day operations of Utilization Review (UR) for precertification, admission, concurrent and retrospective reviews; Report quality of care issues identified during UM process.
• Functions as a clinical resource for the department and internal staff, demonstrating a thorough knowledge of all Utilization Review policies, procedures, and government insurance programs. Also serves as a resource for administrators and contracted vendors.
• Develops, updates, maintains and communicates UR policies and procedures to ensure positive impact and reimbursement in accordance with the mission, values and strategic goals of the organization.
• Assists in the recruiting and onboarding of new hires, orients, and continuously trains employees to ensure success in their role and a thorough understanding of the necessary policies, processes, and procedures of the UR role.
• Develops and performs quality audits on UR staff to ensure accuracy of work on a monthly basis
• Assists in the development of staff performance expectations, metrics, and goals and holds self and staff accountable to achieving. Establishes and communicates performance and behavioral standards and follows the appropriate disciplinary courses of action when counseling staff. (Accountable to KPIs and metrics set by Sr. Management - see Key Performance Indicators section above)
• Reviews daily, weekly and monthly reports to monitor and analyze performance of department, assess data against KPI standards and goals, and identifies trends. Makes adjustments where needed. Keeps leadership, staff, and clinical staff (where appropriate) informed.
• Works closely with Case Management to ensure effective department collaboration. Identifies and maintains good relationships with other departments such as Managed Care, Patient Financial Services, Patient Access, and others so to facilitate the utilization review processes and to provide continuity of care.
• Collaborates with medical staff and hospital personnel as appropriate to ensure effective coverage and precertification requirements are met.
• Communicates