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

Grant Regional Health Center

1 Positions

ID: 1307

Posted On 07/12/2022

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.

Internal applicants: Apply online in ADP Career Center prior to 5:00 p.m. on Tuesday, July 19, 2022.

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!

Posted 7/12/2022

Primary Contact

13199

Stacy Martin

Director of HR,

608-723-3211

Phone

Phone

Phone

Fax

smartin@grantregional.com

Email

True

False

True

Job Details

Categories

Health Care

Location

Lancaster, WI

Shift

First Shift

Job Type

Employee

Full/Part

Part Time

Benefits

Health Insurance
Dental Insurance
Vision Insurance
Life Insurance
Retirement Plan
Paid Vacation
Paid Sick Leave
PTO (Paid Time Off)
Paid Holidays


Qualifications

Education

Associates

Company ID

1046

Job REQ #

1307

# Positions

1

Start Date

20220712

End Date

20221231

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Grant Regional Health Center

About the Company

Grant Regional Health Center is a critical access hospital and clinic located in Lancaster Wisconsin. We are a progressive and growing facility! Our newly opened 47,800 square foot expansion showcases a new med/surg department, new space for our growing multi-specialty clinic, state-of-the art radiology department with in-house MRI, expanded emergency department with enclosed ambulance garage and a rooftop heliport.

Our expanded surgery department features two updated, modern operating rooms, pre- and post-surgical areas, teaching consultation room, as well as dedicated entrance and waiting area. Our Physicians, anesthesia and surgery staff are committed to providing our patients an exceptional surgical experience. They strive to promote a culture-driven environment of excellence, quality, compassion and dignity.

Please join us to experience the difference.  Other enhancements include a new main entrance with amenities such as our gift shop, Perfect Blend coffee shop, healing garden, history and donor recognition wall and additional parking for staff and patients. An additional 39,000 square feet of renovated space wraps up the construction project and symbolizes our commitment to the patient-centered model of care.

We are honored to have achieved 5 Star Rating in Patient Experience for 3 years in a row! That designation puts us in the top 6% of hospitals in the nation! We have also recently achieved Overall 5 Star Rating

We are located in BEAUTIFUL, scenic, and peaceful Southwest Wisconsin. The rolling hills offer lots of opportunity for the sports enthusiast (biking, hiking, ATV/UTV trails, running/walking). The Mississippi is literally 15 minutes from our hospital and offers fantastic boating, kayaking, water skiing, jet skiing and amazing fishing too! Ski resorts within 30 minutes of our facility. Madison WI is 1.5 hours, Dubuque IA is 30 minutes, Chicago IL is 3.5 hours.....we're in the heart of the Tri-States!