Utilization Review/Case Management (RN Required) – Days, Part-Time

Job Overview

TITLE: Utilization Review / Case Management (RN required)

DEPARTMENT: Quality

REPORTS TO: Quality Resource & Risk Manager

POSITION STATUS/HOURS: Part-time position (32 hours/week) Monday – Friday. Hours are approximately 8:00 a.m. – 3:00 p.m. Benefit eligible position!

JOB SUMMARY:

To assist all department heads in the function of utilization review under the umbrella of Quality Resources. Act as a resource person to assist, advise, promote and guide the daily hospital-wide UR activities.  This position is responsible for determining if provider documentation supports medical necessity, if the patient has been placed in the correct patient status and obtaining any required third-party payer authorizations. Communicate with medical staff as needed to promote the care of the patient through the continuum of care.  Attend daily care conference.  Review all charges on the patient’s bill with the documentation held in the medical record for compliance and appropriateness of such.  Assist the Patient Accounting department in denial management; assist with appeals; identify denial trends and help to develop strategies to prevent future denials. Case management functions will include oversight and leadership on the patient care units to promote effective multidisciplinary care of patients and their families from admission to post-discharge. Additionally, provides leadership by working cooperatively with patient care providers and ancillary staff to maintain standards of nursing care in the clinical setting

UTILIZATION REVIEW:

•    Review inpatient admissions for correct type and insurance. Ensure criteria is met for Inpatient / Observation for all medical / surgical and obstetric patients

•    Call insurance company for prior authorization and give clinical update when needed

•    Work with doctors to discuss length of stay

•    Work with all departments to see if patient will benefit from skilled / swing bed stay

•    Address and support cultural practices as long as such practices do not harm others or interfere with the planned course of medical therapy

•    Serve as a member of the Patient Care Conference meeting

•    Attend care meeting to work on discharge planning

•    Train, evaluate and counsel technical and professional personnel performing utilization management activities

•    Develop and implement policies and procedures to support the utilization management processes as outlined in the utilization management plan

•    Demonstrate a high degree of accuracy and attention to details to optimize the cost-effective delivery of care

•    Function as a resource individual to assist with or manage resolution of utilization management issues

•    Demonstrate knowledge of current standards are relating to TJC, CMS, Medicaid, and other entities, in addition to changes in guidelines and methodology for managed care areas

•    Support all health plans and utilization management plans, and refers problem cases to physician advisor and / or medical director when unable to be resolved

•    Review utilization management activities for occurrences and trends that affect the quality, cost effectiveness and delivery of services.  Assure that the outcome of review is appropriately maintained in a database

•    Assist in the resolution of appeals and grievances

•    Implement educational programs for physicians and medical management personnel in the principles and methodology of utilization management

•    Well versed in the procedure for department-specific charges, and assists with charge master review

•    Contribute to product review as needed

•    Assist Quality Resources Department with projects as needed

•    Coordinate, prepare for and lead the Utilization Review Committee, including conducting sub-committee meetings when required for admission review

•    Conduct patient discharge call-backs and follow up on any issues as a result to minimize re-admissions

•    Coordinate Transitions of Care as it relates to discharge of GRCC clinic patient

QUALIFICATIONS:
Required: Registered Nurse. Preferred: inpatient billing/coding and/or health insurance authorization experience. Confidentiality a must and strong computer skills are necessary.

HOW TO APPLY:
Candidate offered employment will complete criminal background check, health requirements (including drug urine), and credit check as condition of employment.

External applicants: Apply on-line at www.grantregional.com and attach an updated resume. Interviews will begin as qualified applicants are received so apply soon!