UM Nurse Supervisor

Description

Professional Duties

• Oversees the daily work flow and work loads of all assigned staff and contracted (non-employee) staff, to ensure the accuracy and timeliness of the referral process, pertaining to hierarchical criteria and provider/member letter notifications as regulated by Health Plans (HP) and Centers for Medicare and Medicaid Services (CMS).
• Conduct all Human Resources (HR) functions, including but not limited to; 90 day and annual performance reviews, all DOHC/HP/CMS compliance and regulatory requirements, adherence to policies and procedures, coaching, corrective actions, PIPs, productivity and ongoing feedback to staff.
• Facilitate/delegate all new employee orientation training, review and assess the need for new and ongoing training, including creating new professional development opportunities for the UM team.
• Prepare, analyze and present reports/trends related to provider medical review compliance, accuracy of criteria used for Physician UM Determinations and timeliness of all required provider and member notifications.
• Complete audits of referrals, both pre and post finalization. Fix noted areas that did not meet compliance based on established Heritage Provider Network (HPN)/HP/CMS audit reference tools.
• Manages payroll-related functions for the UM nursing and contracted teams, including approving time cards, managing time-off requests, and addressing discrepancies with the team.
• Serve as a resource and primary point of contact for UM/Quality Leadership, Physician Medical Reviewers, UM Nurses and contract staff, Director of Referrals, HP Compliance Team, and all other key stakeholders, for questions and inquiries pertaining to pulling medical necessity criteria based on line of business, using appropriate hierarchy in accordance with the established organizational and departmental clinical policies and procedures. Escalates any areas of concern to the appropriate department.
• Manages all departmental staff meetings, daily huddles, Weekly Reads, work flow process updates/changes, and process improvement project process to ensure team alignment with regulatory compliance, department goals and fiscal responsibilities. ject tasks are completed accurately and within established timeframes.
• Assist UM Leadership, (HPN) and DOHC HP Compliance Teams with Corrective Action Plans (CAP). Assist management with review of audit findings, referral review, root causes analysis and action planning.
• Assist management with CAP trending, responses and tracking implementation of corrective action strategies. Keep department management informed of updates and findings.
• Run Health Plan Compliance reports, including Health Industry Collaboration Effort (HICE) upon request and collaborate with department management to ensure that report contains accurate data.
• Serve as a clinical resource between Medical Directors, physician reviewers, and other staff to resolve questions pertaining to review, criteria, denial decision and/or denial letter creation.
• Communicate upcoming authorization expiration of turn-around times to the referral distributors to ensure that referral authorizations are processed within established timeframes.
• Assist UM nursing staff with confirming that the physician reviewer decision is clearly documented in q.Auth notes and confirm that the denial decision matches the criteria cited for the denial letter notification. Follow up with physician reviewer and/or Medical Director for clarification as needed prior to creating denial letter.
• Provide coverage for UM Denial & Criteria nurse as needed.
• Perform other duties as assigned.
• Serve as an ambassador for Desert Oasis Healthcare and Family Hospice Care at all times and positively shape the customer experience.
• Do your share. Do what you say you will do and take action, follow through. Be willing to pitch in and help.
• Be an active listener (make eye contact, validate).
• Be accountable for your work.
• Be sensitive to factors that influence customers and co-worker’s situation including age, gender, culture, race and socioeconomic status. Be observant of others’ social cues (emotions) and respond appropriately.
• Anticipate needs that will arise before your next meeting.

Qualifications

• Bachelor's degree in Nursing (BSN).
• Current California Registered Nurse (RN) license.
• 2 years of quality, compliance and/or utilization review experience. 2 years of managed care and/or healthcare auditing experience.
• Supervisory/leadership experience, preferred.
• ICU and Medical-Surgical background, preferred.
• Knowledge of basic nursing practices and protocols.
• Knowledge of EZ CAP and NextGen or similar programs.
• Ability to communicate effectively with individuals within all levels of the organization, patients, providers, vendors and others.
• Ability to utilize Microsoft Office Suite applications/software (Word, Excel, Power Point, Excel).
• Must be able to work independently and possess strong clinical skills.
• Detailed oriented and well-organized. Ability to manage time effectively and prioritize tasks to meet established deadlines.
• At the discretion of DOHC/FHC management, this position has the potential to be a full or hybrid telecommuting position.

Physical Demands