RN Utilization Manager - Rex Case Management Services Job Raleigh area,North Carolina USA,Nursing

Description

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Summary

Works in collaboration with the patient/family, and interdisciplinary team (including physicians, other care providers, and payors), and assesses the patient care progression from acute care episode through post discharge for quality, efficiency, and effectiveness. The Utilization Manager works collaboratively with other Clinical Care Management staff to ensure patient needs are met and care delivery is coordinated across the continuum. The Utilization Manager completes admission, continued stay, and discharge reviews in accordance with federal regulations & the Hospitals?

Utilization Management Plan. In addition, the Utilization Manager is responsible for revenue protection by reconciling physician orders, bed billing type, and medical necessity. This may include delivering notifications to patients directly. Interface is completed verbally, via email, database tasks, or other electronic communication and via telephone.

Responsibilities

Clinical Review Process - Uses approved criteria and conducts admission review/status change review within 24 hours of patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation status as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments.

Communicates daily with the Case Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the support center to assure third party payor pre‑certification and/or re‑certifications when required. Utilizes high risk screening criteria to make appropriate referrals to Manager.

Discharge Facilitation - Identifies patient/families with the complex psychosocial, ongoing medical discharge planning issues, continuing care needs by initiating appropriate case management referrals. Initiates appropriate social work referrals.

Utilization Management Process - Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts continued stay and quality reviews to monitor the patient’s progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality‑driven, efficient, and effective.

Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels.

Utilization Outcomes Management - Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation status issues through collaboration with patient/family, multidisciplinary team, third party payors and resource center. Provides information regarding denials and approvals to designated entities.

Assists in coordination of practice parameter development with the assigned departments/sections/specialties of Medical Staff. Oversees collection and analysis of patient care and financial data relevant to the target case types. Directs delivery of notifications to patients (includes traveling to hospital(s) to deliver notifications).

Other Information

Education Requirements:

Graduation from a state‑accredited school of professional nursing
If hired after October 1, 2015, must be enrolled in an accredited program within four years of employment, and obtain a Bachelor’s degree with a major in Nursing or a Master’s degree with a major in Nursing within seven years of employment date.

Licensure/Certification Requirements:

Licensed to practice as a Registered Nurse in the…


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