Utilization Management Nurse II - Case Management

Description Summary

The Utilization Management Nurse II is responsible for determining the clinical appropriateness of care provided to patients and ensuring proper hospital resource utilization of services. This Nurse is responsible for performing a variety of pre‑admission, concurrent, and retrospective UM related reviews and functions. They must competently and accurately utilize approved screening criteria (Inter Qual/MCG/ Centers for Medicare and Medicaid Services "CMS" Inpatient List).

They effectively and efficiently manage a diverse workload in a fast‑paced, rapidly changing regulatory environment and are responsible for maintaining current and accurate knowledge regarding commercial and government payors and Joint Commission regulations and guidelines related to UM. This Nurse effectively communicates with internal and external clinical professionals, efficiently organizes the financial insurance care of the patients, and relays clinical data to insurance providers and vendors to obtain approved certification for services.

The Utilization Management Nurse collaborates as necessary with other members of the health care team to ensure the above according to the mission of CHRISTUS.

• Meets expectations of the applicable OneCHRISTUS
  
  Competencies:
  
  Leader of Self, Leader of Others, or Leader of Leaders.
• Applies demonstrated clinical competency and judgment in order to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria in order to determine the appropriate level of care.
• Resource/Utilization Management appropriateness:
  Assess assigned patient population for medical necessity, level of care, and appropriateness of setting and services. Utilizes MCG/Inter Qual Care Guidelines and/or health system-approved tools to track impact and variance.
• Uses appropriate criteria sets for admission reviews, continued stay reviews, outlier reviews, and clinical appropriateness recommendations.
• Coordinate and facilitate correct identification of patient status.
• Analyze the quality and comprehensiveness of documentation and collaborate with the physician and treatment team to obtain documentation needed to support the level of care.
• Facilitates joint decision-making with the interdisciplinary team regarding any changes in the patient status and/or negative outcomes in patient responses.
• Demonstrates, maintains, and applies current knowledge of regulatory requirements relative to the work process in order to ensure compliance, i.e. IMM, Code 44.
• Demonstrate adherence to the CORE values of CHRISTUS.
• Utilize independent scope of practice to identify, evaluate and provide utilization review services for patients and analyze information supplied by physicians (or other clinical staff) to make timely review determinations, based on appropriate criteria and standards.
• Take appropriate follow‑up action when established criteria for utilization of services are not met.
• Proactively refer cases to the physician advisor for medical necessity reviews, peer‑to‑peer reviews, and denial avoidance.
• Effectively collaborate with the Interdisciplinary team including the Physician Advisor for secondary reviews.
• Proactively review patients at the point of entry, prior to admission, to determine the medical necessity of a requested hospitalization and the appropriate level of care or placement for the patient.
• Review surgery schedule to ensure planned surgeries are ordered in the appropriate status and that necessary authorization has been obtained as required by the payor or regulatory guidance (i.e., CMS Inpatient Only List, Payor Prior Authorization matrix, etc.)
• Regularly review patients who are in the hospital in Observation status to determine if the patient is appropriate for discharge or if conversion to inpatient status is appropriate.
• Proactively identify and resolve issues regarding clinical appropriateness recommendations, coverage, and potential or actual payor denials.
• Maintain consistent communication and exchange of information with payors as per payor or regulatory requirements to coordinate certification of hospital services.
• Coordinate and facilitate…