Utilization Review Care Manager - Registered Nurse​/RN

Overview

Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information and Inter Qual guidelines. The Utilization Review Nurse utilizes clinical knowledge to support the coordination and documentation and communication of medical services and/or benefits. The Utilization Nurse also serves on the liaison between the physicians, patients, payers and care managers regarding termination of benefits, denial notification, and expedited appeals.

Has access to highly sensitive, confidential information.

• Evaluates medical records for appropriateness of admission status utilizing a combination of clinical information, screening criteria, and third party information. Collaborates with business office, care managers, attending physicians, and physician advisors as needed
• Conducts self-auditing of medical records for status accuracy and provides peer consultation regarding cases in which patients are failing to progress and/or experiencing significant deviation from the plan of care.
• Educates staff and physicians about managed care principles, observation status, discharge planning, and reimbursement rules.
• Works with Patient Registration/Financial Counselor(s) to identify correct insurance source and proper billing.
• Verifies patient admission information for each assigned patient within 24 hours of patient’s admission (next business day)
• Collaborates with the Case Manager to identify referrals to Financial Counselors.
• Negotiates resolution disagreements over the need for acute hospital level of care with the insurer.
• Collaborates with social workers for patients with complex, clinical, financial and psycho-social needs.
• Reviews physician orders and patient progression and intervenes with care coordination as needed. Collaborates with other departments to eliminate barriers, as necessary.
• Builds trusting relationships with attending physician, patient and/or family and other members of the healthcare team. Establishes a caring relationship with patients and their caregivers, promotes patient engagement and guides patients/families through the transition phase
• In accordance with established clinical guidelines/standards of care establishes a comprehensive care transition plan and will organize, secure, integrate and modify resources necessary to meet the goals stated in the assessment plan.
• Identifies Potential Avoidable Days per department policy.
• Gathers information for statistical monitors, plus special projects within the Care Management Department.
• Maintains records in a complete, detailed, and orderly manner.
• Updates and documents in Midas, pertinent clinical information by utilizing screening criteria and assigns next review date.
• Responsible to support and participate in department strategies and efforts focused on improving length of stay (LOS) and reduction of avoidable readmissions.
• Responsible to support and participate in department strategies and efforts focused on improving clinical documentation by physicians.
• Is knowledgeable of hospital mission, vision, and values and performs in a manner to support them.
• Identifies and reports Quality and Risk Management concerns.

DCH Standards:

• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook.
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• All other duties as assigned.

• Anyone hired after July, 2011 must meet the following:
• Minimum of Registered Nurse with current…