Utilization Management Nurse II - Case Management

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 performs a variety of pre-admission, concurrent, and retrospective UM reviews and uses approved screening criteria (Inter Qual/MCG/CMS Inpatient List). They manage a diverse workload in a fast-paced regulatory environment and maintain current knowledge of commercial and government payors and Joint Commission guidelines related to UM.

They communicate with internal and external clinical professionals, coordinate financial insurance aspects of patient care, and relay clinical data to insurance providers and vendors to obtain approved certification for services. The Utilization Management Nurse collaborates with other health care team members to fulfill the mission of CHRISTUS.

• Meets expectations of the applicable OneCHRISTUS
  
  Competencies:
  
  Leader of Self, Leader of Others, or Leader of Leaders.
• Apply clinical competency and judgment to perform comprehensive assessments of clinical information and treatment plans and apply medical necessity criteria to determine the appropriate level of care.
• Assess the assigned patient population for medical necessity, level of care, and appropriateness of setting and services. Utilize MCG/Inter Qual Care Guidelines and/or health system-approved tools to track impact and variance.
• Use 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.
• Facilitate joint decision-making with the interdisciplinary team regarding changes in patient status and/or negative outcomes in patient responses.
• Demonstrate, maintain, and apply current knowledge of regulatory requirements related to the work process to ensure compliance (e.g., IMM, Code 44).
• Adhere to CHRISTUS CORE values.
• 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.
• 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 medical necessity and the appropriate level of care or placement.
• Review surgery schedules 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 (e.g., CMS Inpatient Only List, Payor Prior Authorization matrix).
• Regularly review patients in Observation status to determine discharge suitability or conversion to inpatient status.
• Identify and resolve issues regarding clinical appropriateness recommendations, coverage, and payor denials.
• Maintain consistent communication with payors as required to coordinate certification of hospital services.
• Coordinate and facilitate patient care progression across the continuum and document to support medical necessity at each level of care.
• Evaluate care provided by the interdisciplinary health care team and advocate for standards of practice.
• Analyze assessment data to identify problems and formulate goals/outcomes.
• Follow CHRISTUS guidelines related to HIPAA to prevent unauthorized disclosure of PHI.
• Attend scheduled department and interdepartmental meetings as appropriate.
• Demonstrate technology literacy and ability to work in multiple technology systems.
• Act as a catalyst for change; respond to change with flexibility and adaptability; collaborate for change.
• Translate strategies into action steps; monitor progress and achieve results.
• Display confidence, drive, and the ability to overcome challenges to achieve organizational goals.
• Demonstrate competence to perform assigned responsibilities in a manner that meets population-specific and developmental needs of patients served by the department.
• Possess negotiating skills to interact with physicians, nursing staff, administrative staff, discharge planners, and payers.
• Exhibit excellent verbal and written communication skills, knowledge of clinical protocol, normative data, and health benefit plans, including coverage and limitation clauses.
• Adjust to changing workloads and frequent interruptions.
• May work overtime or take calls; may travel to other facilities as needed.
• Participate in Multidisciplinary/Patient Care Progression Rounds.
• Escalate cases as…