Hospital Reviewer​/Utilization Manager at Doctors Healthcare PLANS, INC

Hospital Reviewer/Utilization Manager job at DOCTORS HEALTHCARE PLANS, INC.. Coral Gables, FL.

• Uses a collaborative process to plan, assess, re‑assess, implement, monitor, and evaluate the options and services required to meet the healthcare needs of the patients using the functions of Utilization Resource Management, Transition of Care, Discharge Planning, and Case Management.
• Reviews the appropriateness of Severity Index/Intensity of Service for all acute care admissions utilizing evidence‑based criteria guidelines within the appropriate time frame.
• Notifies the Medical Director of all acute care admissions not meeting evidence‑based criteria potential/actual denials.
• Presents case for patients not meeting criteria for medical necessity for the requested level of care/patient status to the Medical Director.
• Proactively identifies, and resolves delays and obstacles for safe discharge. Seeks consultation from appropriate disciplines/departments to expedite care and facilitate safe discharge.
• Communicates with multiple resources and payors to identify appropriate vendors for obtaining authorization for ancillary/hospital services to facilitate transition to appropriate level of care.
• Collaborates with family, health care team, payors, and providers to achieve appropriate resource management to implement safe discharge plan of care established by health care team and family.
• Assists in identifying and reporting variances in utilization of resources, avoidable days/denials. Works in collaboration with Appeals Management/Medical Director in the appeals process.
• Responsible for the appropriate use of software and applications, and enters case management information accurately and in a timely manner.
• Adheres to Medicare and Medicaid regulatory guidelines as it pertains to patient admission/safe discharge.
• Provides after hour safe discharge coverage for all hospital units.
• Participates in utilization management initiatives/opportunities for improvement through departmental committee assignments.

• Registered Nurse or Licensed Practical Nurse.
• Current and valid license to practice as a Registered Nurse or Licensed Practical Nurse in the State of Florida.
• 3 years minimum experience in discharge planning, utilization management, or case management.
• Basic proficiency in Microsoft Word, Excel, and Outlook.
• Demonstrates commitment to the Partners-in-Caring process and the behavioral expectations in all interactions and in performing all job duties.
• Performs duties in a manner to promote quality patient care.
• Able to communicate effectively both verbally and in writing in a clear, concise, and courteous manner.
• Fluent in Spanish preferred.
• Working experience with electronic medical records, and/or discharge planning and case management systems.
• Able to maintain confidentiality of sensitive information.
• Able to work in a fast-paced environment, and effectively manage and use resources to successfully meet the competing deadlines of a variety of tasks, problems, and projects.
• Able and available to work a flexible/rotating schedule, including holidays and weekends.

Note:

This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.