Utilization Review Rn Jobs in Miami, FL (NOW HIRING)

Job Summary

Responsible for providing leadership and management of clinical care coordination, utilization management, and discharge planning. Assists the Director with patient-centered systems, processes, and outcomes of clinical care teams and programs designed to address clinical, psychosocial, and financial needs of patients and families. Responsible for training, supervision, and evaluation of team members, and participation in goal setting, program planning, workflow process monitoring, regulatory compliance, staff productivity, and assessment of good customer service, quality of work, outcome evaluation, and continuous quality improvement. Participates in and/or conducts LEAN and other quality improvement efforts.

Job Specific Duties

• Ensures compliance with Utilization Review Annual Plan, JC/DNV-GL, CMS/Federal and State requirements, and professional standards for case management, utilization review/utilization management, discharge planning/care coordination, and transitions of care through policy and procedure development, implementation, and monitoring of standard work. Ensures documentation compliance of the care management department and assists and develops action plans to address variances.
• Communicates as a role model for the organization’s Service Standards in performance of duties and interaction with patients, families, staff, and all disciplines.
• Assists Director in designing, implementing, and maintaining efficient systems and processes which promote departmental efficiency, productivity, and assure compliance with regulatory standards. Controls work operations by establishing and implementing objectives, practices, and methods; and develop corporate care management strategies.
• Supports the daily operations of the care management department (Inpatient/Outpatient/Emergency Dept) and assesses and regulates staff compliance with the Hospital’s high standards for exemplary customer service and communication. Promptly investigates problems/complaints and resolves when possible.
• Acts as an administrative liaison with third party insurers as appropriate to facilitate resolution of medical necessity determinations and fiscal denials. Monitors reports, unusual incidents, patterns, and processes within the department, and recommends changes and improvements. Advocates and escalates plan of care delays.
• Fosters an exceptional teamwork environment with nursing teams and interdisciplinary colleagues; coaches staff in building strong team dynamics. Promotes professional growth and development of employees. Maintain annual education, participation and involvement with qualified Care Management, and other education platform that support acute care, academic, and ambulatory care environment. Contribute to elevate quality of care and improve outcomes with evidence-based healthcare solutions.
• Meets regularly with Director and staff to share plans and ideas, and performance improvement strategies per departmental plan. Meets regularly with staff to ensure employee engagement across the department and that staff receive consistently clear information, direction, and assistance.
• Participates in development and implementation of appropriate patient/family education material pertinent to population served. Participates in development of quality indicators and analysis of such indicators per departmental quality & performance improvement plan. Identifies and implements strategies to support Hospital and departmental missions and priorities, contributes or co-leads quality improvement committees, and initiatives using evidence-based practice to initiate change and to drive improvement strategies.
• Assists team members to establish effective collaborative relationships with representatives of third-party payors and external health care agencies in ways that contribute to these providers’ development of an enhanced image of our hospital and health systems.
• Establishes stewardship of financial, material, and human resources that assist the Director in managing resources to meet budgetary goals while responding effectively to necessary program changes and altered staffing levels. Maintain and/or provide input for schedules and utilizes staff with flexibility so that the workloads are equitably distributed and productivity goals are met.
• Provides positive communication skills in establishing and fostering professional working relationships and uses consistent positive communication skills when offering assistance or making suggestions.
• Monitors, controls, and evaluates the quality and quantity of the staff effectiveness and work products. Recruits, orients, coaches, develop, supervise, and evaluates direct reports that contributes to staff retention within the department. Assists all employees enhance and maximize skills necessary for great performance.

Minimum Job Requirements

• Bachelor's Degree BSN from an accredited RN program  
• RN - Registered Nurse RN Licensure within the State of Florida or Multi-State Enhanced Nursing License Compact (eNLC) – maintain active and in good standing throughout employment
• 3-5 years Clinical experience
• 4-7 years Case management or utilization management with some discharge planning experience
• 4-7 years Supervisory or management experience in related setting and program function

Knowledge, Skills, and Abilities

• Master's of Science in Nursing preferred.
• Case Management Certification or equivalent in Case Management, American Board of Quality Assurance and Utilization Review Physicians, Inc. (ABQAURP) or Certified Professional Healthcare Quality (CPHQ) preferred.
• Membership in case management and/or related specialty professional organization preferred.
• Transitions of care experience preferred.
• Knowledge and understanding of laws, rules, regulations, and reimbursement regarding managed care and commercial insurance and federal and state government programs such as Medicaid and Medicare.
• Demonstrated leadership and organizational abilities.
• Demonstration of consistency, independence, flexibility, initiative, creativity, resourcefulness, effective written and verbal communications, diplomacy, organizational, and analytic skills.
• Self-directed, assertive, and creative in problem solving, systems planning, and patient care management.
• Skill in analyzing information, data, and problems.
• Ability to design and/or implement data collection tools.
• Strong analytical skills.
• Competent to expert use of Microsoft Office.
• Demonstrated proficiency in managing software such as Cerner Millennium, Meditech, EHR/EMR, EPIC, Allscripts, and other related software.