Job Description

Job Description Summary

Under the general supervision of the Utilization Management Manager acts as a patient advocate/Case Manager to SSH. Provides Utilization Review (UR) RNs guidance on prioritizing and completing daily tasks to ensure medical necessity criteria is met and to facilitate patients through the continuum of care. Performing the responsibilities below assist with status management, medical necessity reviews, verification of authorization, resource utilization, and denial prevention. The UR Nurse is expected to use best clinical judgment as priorities may shift throughout the day. Works collaboratively with interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. The UR Nurse is on-site and available seven (7) days a week as well as holidays and, therefore, is required to work a weekend rotation and also an occasional holiday.

Job Description

Job Responsibilities:

• Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of hospital admissions.

• Complete clinical admission reviews within 24 hours of admission on all observation (OBS) and inpatients (IP) using medical necessity guidelines

• Submit initial clinical reviews within 24 hours of notification to payer to ensure authorization for admission (e.g., fax, secure email, web submission)

• Confirm payer authorization within 24 hours of admission, and communicate with payers in collaboration with insurance verification as necessary

• Performs concurrent reviews for patients to ensure that extended stays are medically justified and are so documented in patient's medical records.

• Ensure Utilization Management policy/processes are followed for those patients who do not meet criteria for ordered status

• Conduct scheduled/structured daily touch points with CM/SW for updates on plan of care or changes of clinical status not documented

• Discuss issues related to the plan of care, LOC, medical necessity, length of stay, and payer communication 

• Discuss avoidable delays and denials as appropriate

• Participate in the weekly clinical high risk (CHR) meetings 

• Review all concurrent denial notifications and ensure appropriate medical necessity criteria was applied 

• Coordinate peer to peer (P2P) reviews for concurrent denials

• Refers to the standard workflow for cases that do not meet established guidelines for admission or continued stay and escalates appropriately.

• Assists the Utilization Review Committee in the assessment and resolution of utilization review problems.

• May participate in identification of problems related to the quality of patient care and refers them appropriate stakeholders for process improvement

• Compiles monthly reports and statistics for presentation to the Utilization Review Committee.

• Interacts, communicates, and intervenes with multi-disciplinary healthcare team in a purposeful, goal-directed fashion. Works pro-actively and utilizes critical thinking skills to maximize the effectiveness of resource utilization. Anticipates, initiates, and facilitates problem resolution around issues of resource use and continued hospitalization, discharge planning.

• Establishes a means of communicating and collaborating with physicians, other team members, the patient’s payers, and administrators.

• Explores strategies to reduce length of stay and resource consumption within the care managed patient populations, implements them and documents the results.

• Communicates to appropriate members of healthcare team patients at risk of losing insurance coverage via termination of benefits, facilitates discharge plan

• Maintains a pro-active role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement

• Reviews physician documentation and follows procedures to seek clarification where indicated of that documentation relative to diagnosis and comment on the patient’s clinical state.

• Participate in daily multidisciplinary patient care rounds.

• Acts as a clinical resource to support the Case Manager/SW in resource utilization and discharge planning the more clinically complex or long length of stay patient.

• Maintains consistently a professional commitment to institutions and department’s goals and objectives.

• Demonstrates flexibility to the department’s needs in relation to floor and work schedule, and any other internal and external demands on the department.

• Continually shows commitment to the Department by extending self when need arises.

• Attains all agreed to goals and objectives within specified time frames, as part of the organization’s overall mission.

Job Requirements:

Minimum Education - Preferred

Registered Nurse, Bachelor's prepared strongly preferred

Minimum Work Experience

3-5 years acute care hospital experience preferred
2-3 years case management experience preferred
1 year Utilization Management preferred

Required Licenses / Registrations

RN - Registered Nurse

Required Certifications

ACM - Accredited Case Manager or CCM - Certified Case Manager within two years of hire.

Required additional Skills, Knowledge and Abilities:

• Demonstrated skills in the areas of: negotiation, communication (verbal and written), conflict, interdisciplinary collaboration, management, creative problem solving, and critical thinking, time management and ability to multitask in high stress environment.

• Knowledge of: healthcare financing, community and organizational resources, patient care processes, and data analysis.

• Knowledge of utilization management as it relates to third party payers

• Experience with Managed Care preferred.

• Excellent verbal and written communication skills required.

• Demonstrates flexibility via an ability to adapt to changing priorities and regulations.

• Proficient with Microsoft Office Suite or related software

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