Clinical Resource Management Nurse; RN - Case Coordination

Location Detail: MMH-71 Haynes Street (10627)

Shift Detail: All shifts available

Work where every moment matters.

Every day, over 40,000 Hartford Health Care colleagues come to work with one thing in common:
Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut’s most comprehensive healthcare network.

The Greater Manchester Region has approximately 2,500 employees. It includes Manchester Memorial Hospital, a 249-bed community hospital, Rockville General, a campus of Manchester Memorial Hospital, a 102-bed facility, a large multispecialty provider group and visiting nurse services. The Greater Manchester Region serves a region of 300,000 people in 19 towns.

POSITION SUMMARY:

The Utilization Review Case Manager (UR CM) works in collaboration with the physician and interdisciplinary team to support the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. The role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care, promoting clinical best practice, and ensuring all patients receive “the right care, at the right time, and in the right setting”.

The UR CM is responsible for preoperative, concurrent, and retrospective reviews in accordance with the utilization management plan. The UM CM ensures the appropriate status and level of care is determined and ensures accurate assessment of medical necessity, thus appropriate reimbursement. Performs duties in support of ECHN mission to ensure the highest quality of patient care in an economically sound and efficient manner.

EDUCATION/CERTIFICATION:

• Bachelor’s Degree in Nursing or a related field.

• Current licensure as an RN.

EXPERIENCE:

• 2 – 3 years’ experience in case management, discharge planning, and/or progression of care in the acute-care setting.

• Minimum of 1 year Utilization Review experience preferred via industry clinical standards, i.e., Inter Qual, Milliman Care Guidelines.

COMPETENCIES:

• Comprehensive knowledge of the health care reimbursement system.

• Demonstrated skill in creative problem-solving, facilitation, collaboration, coordination, and critical thinking.

• Excellent demonstrated oral, written and communication skills.

• Proficiency in the use of work processing and spreadsheet application.

ESSENTIAL DUTIES and RESPONSIBILITIES:

Disclaimer:
Job descriptions are not intended, nor should they be construed to be, exhaustive lists of all responsibilities, skills, efforts or working conditions associated with the job. They are intended to be accurate reflections of the principal duties and responsibilities of this position. These responsibilities and competencies listed below may change from time to time. Eastern Connecticut Health Network reserves the right to change or assign other duties and responsibilities to this position

• Conducts concurrent and retrospective review(s) utilizing Inter Qual (IQ), Milliman Care Guidelines (MCG), or in accordance with CMS rules and regulations for medical necessity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department policy/procedure; refers appropriate cases to Physician Advisor for recommendation(s).

• Ensures order in chart/EMR and status coincides with the IQ or MCG review or CMS rules and regulations for appropriate Level of Care and status on all patients through collaboration with Case Manager.

• Demonstrates thorough knowledge in the application of medical necessity criteria.

• Assess the safest and most efficient care level based on severity of illness, comorbidities and complications, and the intensity of services being delivered.

• Utilizes appropriate payer criteria to provide recommendation(s) to the attending physician

• Communicates payor criteria and issues on a case-by-case basis with multidisciplinary team and follows up to resolve problems with payors as needed; initiates peer to peer when appropriate.

• Contacts the attending physician for additional information…