Case Management Utilization Review RN
The Care Manager assumes primary responsibility for documentation of appropriate medical necessity for the inpatient status or placement in observation. Communicates with the physicians and clinicians. Assures clinical information is sent to the payor timely to complete the authorization of the patient stay. Collaborates and coordinates with other allied health professionals to ensure quality care is provided and desired outcomes are achieved in a timely and cost-effective manner.
- Utilizes a complete and systematic methodology/process to assess, plan, implement, evaluate and provide patient care coordination from pre-hospital through post-hospital care.
- Assists in the development of physician profiles to identify over/under utilization patterns.
- Supports Steward Health Care's and hospital goals and objectives. Works within regulatory compliance guidelines.
- The Care Manager works collaboratively with all healthcare disciplines to assure appropriate and timely services.
- Assesses the medical appropriateness, quality, and cost-effectiveness of proposed hospital, medical, and surgical services.
- Collaborates with the multidisciplinary team to assist patient with benefits management.
- Communicates with payers to obtain authorization.
- Identifies and plans strategies to optimize inpatient length of stay and resource utilization.
REQUIRED KNOWLEDGE & SKILLS:
- Ability to work competently with computer-based charting and other clinical and non-clinical software programs.
- Adaptability to change and good organizational skills required. Ability to read and communicate effectively in English.
- Can be expected to do presentations as directed. Working knowledge of criteria for Medicare, Medicaid, HMO, and private insurance carrier’s coverage details.
- Ability to advocate for patients. Ability to operate office equipment. Possess critical thinking skills.
- Leadership skills required for role include effective mentoring, coaching, counseling, time management, problem solving, and strategic planning.
- Demonstrates initiative and proactive approach to problem resolution.
- Ability to effectively interact with insurance companies and community healthcare recourses.
- Ability to work in a stressful, fast paced environment.
- Must master Microsoft Office Products, i.e. Excel, Word etc.
- Understand CMI, patient status, InterQual Criteria, Milliman Criteria, and Transfer DRGs.
- Has the maturity to work independently and remotely.
- Education: Bachelor’s degree required; Master’s degree preferred.
- Experience (Type & Length): Three to five years of acute medical/surgical experience plus three to five years of Case Management experience.
- Certification/Licensure: RN license required; Certification in Case Management (CCM) strongly preferred.
- Software/Hardware: Strong knowledge in Microsoft Office applications – Word, Excel, Access, PowerPoint.
- Other: Understanding of the health care delivery setting.