Position Summary
The Case Manager Utilization Review utilizes the nursing process for age and diagnosis of specific populations to assess, plan and evaluate the care of a designated case load of patients so that clinical and financial outcomes are achieved. Holds primary responsibility for oversight of Care Coordination and Utilization Review for all patients, providing direction and delegation as appropriate. Responsible for appropriate utilization of medical necessity criteria and provides guidance to medical and other clinical staff in their use.
Work Schedule
Flexible schedules to cover all shifts and weekends, as hospital needs demand.
Primary Duties
Utilization Review:
- Maximizes positive financial outcomes for his/her designated case types.
- Develops and demonstrates organizational skills and effective time management skills on a daily basis.
- Compares and contrasts resource utilization before and after a planned change.
- Identifies and implements changes/strategies to improve profitability of targeted case types.
- Ensures optimization of reimbursement through assignment of proper coding for specific cases.
- Monitors and analyzes variances from standard and individualized clinical paths.
- Assesses efficiency and cost effectiveness of interdepartmental systems.
- Identifies and communicates problems/inefficiencies in interdepartmental operations to the Director, Case Management.
- Assists the Director, Case Management in planning, implementing and evaluating strategies to correct/improve problems/inefficiencies.
- Performs and/or delegates admission and continued stay review for all payers and levels of care; performs these responsibilities within 24 hours of admission and continued stay reviews not less than every three (3) days.
Utilizes consistent processes to assure that all patients are evaluated and monitored for appropriate resource consumption.
- Applies utilization review criteria objectively for admissions, continued stay, level of care and discharge readiness, using Milliman Care Guidelines or other facility criteria guidelines.
- Screens and coordinates admissions and transfers, including emergency and elective care, observation status, conversions from outpatient to inpatient care and out-of-area transfers.
- Participates in the investigation and collaborates with the attending physician in case denials and appeal process.
- Collaborates with the attending physician when the medical record documentation does not reflect admission or continued stay criteria and confers with Case Management Director and/or Medical Director for assistance when consensus cannot be reached with the attending physician.
- Ensures facility processes for working with external reviewers is followed in a timely and complete manner.
- Communicates external UR determinations to patient and/or family when applicable.
Participates in the Case Management/Utilization Review Committee formal processes.
- Collects and aggregates utilization data for tracking and trending reports.
- Coordinates and maintains data to address issues of over-utilization, under-utilization and admission necessity.
- Attends CM/UR Committee meetings as assigned.
- Actively collaborates with CM Medical Director to maximize appropriate and efficient care of patients.
- Is knowledgeable of and supports the AHH Utilization Review Plan.
- Assists with coordinating peer review, focused reviews or other studies as directed by the CM/UR Committee.
Communicates effectively with patients, families, physicians, staff and other customers.
- Communicates clearly and accurately in both verbal and written form.
- Consistently demonstrates tact, diplomacy, sensitivity and professionalism.
- Exhibits appropriate telephone protocol.
- Adheres to proper channels of communication in a courteous and cooperative manner.
- Acknowledges each patient complaint within the shift and takes appropriate action.
- Greets patients and visitors promptly and makes them feel welcome.
- Utilizes correct procedure in regard to hospital information systems and communication with ancillary departments.
- Communicates, coordinates and conducts at a minimum weekly inter-disciplinary health team conferences for individual case types.
Contributes to modifications in nurse and physician practice patterns to continuously improve quality of care, patient satisfaction and appropriate use of resources.
- Maintains current knowledge of national standards or practice, as well as Joint Commission standards, appropriate to medical and nursing specialty.
- Identifies educational needs of individual or groups of clinical staff through daily contact; conducts informal education of staff, as appropriate; communicates learning needs to the appropriate Director and/or Clinical Educator.
- Identifies and communicates clinical staff practice variances to the appropriate Director.
Dimensions of Patient Care Employee:
- Identifies and corrects conditions that affect employee safety; upholds safety standards.
- Maintains stable performance under pressure or opposition; handles stress in a manner that is acceptable to others and to the organization.
- Makes customers and their needs a primary focus on one’s actions; develops and sustains productive customer relationships.
- Having achieved a satisfactory level of technical and professional knowledge in position related to areas, maintains current development and trends in area of expertise.
- Clearly conveys information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.
Qualifications/Specifications
- Education: Graduate of an accredited program of nursing required: RN required; BSN preferred.
- Licensure/Certification: Current state issued license required. Nurse may have license from a state within Nursing Compact.
- Experience: Minimum of 2 years clinical experience in cardiovascular nursing preferred. Two years of case management experience preferred.
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