Case Manager ​/ Utilization Review Nurse

Overview

Provides discharge planning and utilization review services in compliance with patient’s discharge planning needs and the hospital’s utilization review program.

This position is designated as “Safety Sensitive Position” under Act 593 of the State of Arkansas. An employee who is under the influence of Marijuana constitutes a threat to patients/customers. Conway Regional is responsible for providing and supporting the delivery of health care related services.

• Apply clinical knowledge to determine appropriate acuity levels and utilization through chart review.
• Effectively organize workflow to consistently complete assignments in a timely manner.
• Demonstrate ability to access and effectively utilize primary sources of data.
• Obtain and maintain medical records in conformance with Medical Information policies.
• Communicate with co-workers in a manner conducive to positive and effective working relationships; demonstrate respect, honesty, and integrity when working with other service providers.
• Comply with all relevant hospital, state and federal requirements related to maintenance of confidentiality of persons, data and information systems.
• Takes advantage of opportunities made available through CRHS and other professional organizations for continued professional growth and development.
• Responsible for analysis of patient information for determination of necessity of admission or continuation of stay.
• Review for medical necessity of admission on the first working day after admission using approved review criteria.
• Review inpatient procedures to determine appropriate utilization and acuity level; review potential for outpatient setting or swing bed utilization.
• Review all patients for medical necessity of continued stay, or before the next review date, using approved review criteria.
• Perform retroactive reviews, as necessary, and respond to the appropriate review agency or third-party payor.
• Research denials issued by review agencies and third-party payors and respond within the specified time frames for appeal.
• Work with others on healthcare team to coordinate for patients discharge needs.
• Establish an effective utilization review process and maintain an active, effective utilization review file system. Recommend, develop and revise policies related to the utilization review process.
• Work collaboratively with physicians, Case Management, the discharge planning process, Admissions, Central Scheduling and other CRHS associates.
• Educate staff, physicians and other personnel regarding medical necessity requirements as defined by approved review criteria.
• Assist with other department functions as assigned.

• Registered Nurse or Licensed Practical Nurse with current, active license to practice in Arkansas, required.
• Proof of the highest level of nursing education achieved, required.
• At least one-year experience in the area of case management/utilization review, preferred.