Utilization Review Manager- RN

Description

General Responsibilities:

  • Maintains PHI and HIPAA for each patient in accordance with hospital policy and federal regulations.
  • Promotes safety in the workplace and a safe patient environment at all times
  • Practices “minimum information necessary” when performing UR, case management and discharge functions
  • Acts as a patient advocate for all facility patients
  • Adheres to all company and professional ethical, legal and accreditation/regulatory standards
  • Respects and promotes individual patient privacy and confidentiality
  • Demonstrates knowledge and support of the organization mission, vision, values and strategic initiatives.
  • Demonstrates understanding of and upholds the organization’s Quality, Risk and Continuum of Care program philosophy.

UTILIZATION MANAGEMENT RESPONSIBILITIES (75% of time performing duty)

  • For all hospital admissions, this position will review medical necessity using InterQual criteria within 2 business days of admission and will be based on medical record documentation on chart within 48 hours of admission and document using the appropriate UR form. Assisting with Pre-admission referral reviews, concurrent, and discharge criteria review, as needed.
  • Completes ongoing concurrent and discharge UM reviews at least every 7 days. All UM reviews will be documented per policy. UM process for referral of cases to Physician Advisor/Medical Director will be followed when appropriate.
  • Participates in weekly UM meetings to review all DRG outlier cases for appropriateness of admission and discharge as well as need for continued stay. Barriers are identified and appropriate physician intervention is obtained when necessary.
  • Completed all UM reviews within stated time frames and follows UM process for additional clinical reviews when necessary.
  • Provides clinical updates to third party payors after admission within stated time frames to obtain continued stay authorization. All interactions and results of interactions with third party payors are documented in the MEDITECH system. This documentation includes: Level of care, rates, number of days approved and date next review is due.
  • Provides utilization management equally to all patients regardless of payor source.
  • Maintains documentation in chart in timely fashion and communicates any changes timely to third party payors to update authorization of ongoing medical care appropriate to patient needs.
  • Uses DRG and InterQual as tools when applicable to assist in appropriate management of patient medical services and to facilitate discharge to the appropriate level of care in a timely and cost-effective manner.
  • Identifies/tracks/trends/analyzes selected variations (variance=patient/family, practitioner, system, or community) which affect patient care, resource management or length of stay. Completes statistical and other reports as required in a timely manner.
  • Ensures utilization of medical resources for patients efficiently and effectively
  • Maintains a safe environment
  • Participates in Quality Improvement, UM Committee and Risk Management as indicated
  • Attends department meetings and mandatory in-services
  • Performs other duties as assigned.
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Job Requirements

Experience

  • Two (2)-three (3) years of experience in hospital case management, utilization management or discharge planning of complex medical/surgical cases
  • Proficient with use of InterQual, Milliman or other national recognized criteria
  • Strong analytical and organizational skills
  • Working knowledge and ability to apply professional standards of practice in work environment.
  • Knowledge of specific regulatory, managed care and accreditation requirements
  • Computer proficiency

Education Required

  • Minimum Bachelor’s degree in nursing (BSN)

Additional Information

LICENSURE/CERTIFICATION:

  • Must maintain current licensure in good standing during employment, as applicable
  • Must obtain CEU’s in accordance with state requirements for licensure