Job Description

POSITION SUMMARY:
The Utilization Review Case Manager validates the patient’s placement to be at the most appropriate level of care based on nationally accepted admission criteria. The UR Case Manager uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay. The UR Case Manager secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required. The UR Case Manager follows the UR process as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review.
KEY RESPONSIBILITIES:

Utilization Review Management as evidenced by:

  • Reviews patient admissions for appropriateness of admission, inpatient versus outpatient status, expected length of stay, level of care and medical necessity utilizing screening tools such as InterQual, MCG and the Medicare Two Midnight Rule.
  • Identifies and monitors Observation status patients concurrently to ensure appropriate utilization of Observation status within defined payer rules.
  • In cases where the documentation does not support the current level of care, communicates with the admitting physician to request additional supporting documentation or reconsideration of the patient’s current level of care.
  • Manages timely communication of pertinent clinical data to support admission, clinical condition, continued stays and authorization of post-acute services.
  • Proactively works to secure reimbursement resources needed for patient care.
  • Advocates and monitors for the appropriate utilization of resources.
  • Utilizes defined methodology for tracking avoidable delays/days and uses this information to identify opportunities for improvement.
  • Actively participates in performance improvement activities relevant to identified opportunities for improvement.
  • Works to minimize medical necessity denials by providing education regarding the need for detailed physician documentation of the patient’s clinical issues.
  • Provides all clinical information necessary to support written responses to payers regarding cases where reimbursement by a payer(s) was denied.
  • Obtains timely insurance authorizations/certifications from all payers requiring authorization of hospitalizations, tests, procedures, medications, etc
  • Maintains current information on insurance requirements according to payor grid.

Clinical Resource Management as evidenced by:

  • Evaluates and makes recommendations to the appropriate resource/committee related to quality, safety, access, and cost-effectiveness in the course of assessing, monitoring and evaluating resources for patient care.
  • Educates members of the healthcare team and patients and/or family members on the economic impact of their care options.
  • Facilitates timely progression to the next appropriate level of care through on-going communications with the case management and healthcare teams.
  • Identifies and reports avoidable delays/days caused by inefficient workflow processes that may require modification to support cost-effective care. Uses the Chain of Command escalation process as needed.
  • Proactively uses knowledge of hospital/payer contracts to ensure appropriate reimbursement and utilization of patients benefits.
  • Obtains the appropriate payer authorization to advance the plan of care as necessary.
  • Applies medical necessity criteria to monitor the occurrence of over or under utilization of services.
  • Maintains knowledge of current Federal, State and payer regulatory requirements pertinent to utilization review processes.
  • Documents all relevant authorization information in the patient’s medical record and/or case management documentation system according to departmental standards and policies
  • Proactively identifies when a patient is no longer meeting medical necessity for the current level of care and communicates with the healthcare team to develop an appropriate transition plan
  • Partners with payers to ensure patient access to his/her full benefits and negotiates for benefit exceptions as needed.
  • Participates in the identification, collection and analysis of data trends related to length of stay, avoidable days, and readmission rates.
  • Maintain awareness of evidenced-based case management and utilization review practices in the area of assignment.
  • Demonstrates initiative to seek new knowledge and expand professional practice.
  • Participates in educational programs relevant to scope of practice.
  • Participates in routine huddles with Care Coordinator Case Manager and Social Worker to facilitate transition management.
  • Works collaboratively with all members of the Case Management department to provide comprehensive case management services to the patient/family.
  • Performs other duties as requested.

REQUIRED KNOWLEDGE & SKILLS:

  • RN - Registered Nurse
  • Previous experience in Case Management including knowledge of Interqual criteria, Milliman, Medicare Two Midnight Rule and Utilization Management preferred.
  • Skills include the ability to review cases for appropriate status of care, continued stay and the utilization of discharge screens.
  • Possess strong communication, problem solving and organizational skills.
  • Must be proficient in word processing and the use of clinical software.
  • Knowledge and Experience with Electronic Health Records: Meditech knowledge beneficial
  • Current knowledge of utilization review and resource management processes in an acute care setting
  • Knowledge of CMS, Medicaid, commercial payer requirements, and financial and reimbursement processes

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

Minimum Education:

  • RN clinical licensure required (Bachelor’s degree preferred)

Minimum Experience:

  • Experience and certification in case management preferred; case management certification expected within 2 years of hire
  • 5year minimum in acute nursing experience

Minimum skills/abilities:

  • Strong collaboration, communication and interpersonal skills
  • Excellent organizational and time management skills
  • Knowledge of computers, Electronic Health Records, data base systems and utilization review/case management documentation systems
  • Desire to work collaboratively and proactively with healthcare teams and other hospital interdisciplinary teams
  • Excellent written/verbal communication skills, critical thinking skills, creative problem-solving skills, good organizational and planning skills
  • Must be self-directed, have the ability to tolerate frequent interruptions and work in a fast-paced work environment Knowledge of funding, resources, services, clinical standards, utilization review processes and outcomes is preferred.
  • Able To Keep Confidential Information Regarding Patients, Team Members

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