- Support the achievement of hospital-wide case management and utilization goals by developing, supporting and evaluating utilization management and third party review activities.
- Maintain an up-to-date understanding of health insurance options and policies.
- With the support of systems such as MCG, identify and document non-acute Level of Care (LOC) through application of evidence-based clinical decision support system criteria and communicates to appropriate staff as needed. Interact with physicians regarding LOC concerns and facilitate transfer of patients to more appropriate LOC as needed.
- Utilize evidence-based clinical decision support system criteria to concurrently review cases for appropriateness of admission and continued stay. Document, timely, the specific data (Severity of Illness and Intensity of Service) to support admission/continued stay in documentation tool and/or EMR.
- Refer to physician advisor as appropriate and initiate recommendations. Coordinate appeal process with the physician advisor to ensure denials are appropriately appealed in a timely fashion.
- Collaborate with external review agents to coordinate concurrent and retrospective utilization review activities. Manage and coordinate third party review activities. Serve as liaison for review agents.
- Trend, monitor, identify and appeal denials in accordance with Medicare Conditions of Participation.
- Coordinate timely submission of clinical supporting documentation.
- Collect and analyze data on various utilization metrics for presentation and discussion at monthly UM meeting; including but not limited to, denials, avoidable days, admissions, readmissions, etc.
- Responsible for annual QI presentation on department quality initiatives.
- Support for case management role as needed
- Demonstrates collaboration with nursing, social work and other members of the healthcare team to complete ongoing thorough and timely documentation of discharge planning assessments and plan of care.
- Screening for medical necessity upon admission, concurrently and retrospectively.
- Ensures that required documentation is completed such as, but not limited to, IM, Choice letters (ROI), MOON, NOMC and swing bed admission and discharge paper work.
- Performs assessment and documentation of physical, psychosocial and economic needs for transition of care planning to a variety of levels of care.
- RN required. Bachelor's Degree preferred. Certification in Case Management a plus.
- Five years' experience working in a healthcare organization, with at least three years of utilization review, case management, or discharge planning experience preferred.
- Certified Managed Care Professional (CMCP) desired within (1) year of hire.
- Knowledge of overall hospital operations, especially in areas of reimbursement and regulatory matters (Federal/State government).
- Excellent verbal and written communication skills and ability to act in an assertive, innovative and diplomatic manner. Able to communicate effectively.
- Computer literacy and analytic skills required. Experience with UR Software preferred (Interqual/ MCG etc.).
- $35-44 / hour
- Medical, Dental, Vision
- Employer paid Life Insurance
- Disability Insurance
- Critical Illness & Accident Insurance
- 403(b) with employer match
- Earned time accrual for paid time off
- Tuition Assistance
- Student Loan Pay Down Program
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Manager of Care Transitions - Manchester, United States - Huggins Hospital
Description
Job Description - Case Management NurseCase Management Nurse
(
)
Under the general supervision of the Director of Quality & Risk, the Utilization Review Nurse is responsible for utilization review and inpatient case management activities to promote patient safety and quality care.
The Utilization Review Nurse will conduct medical necessity reviews in accordance with the Utilization Management Plan for patients that are on a nursing unit to include:Inpatient admissions, Observation and Outpatients in a Bed status. The Utilization Review Nurse will identify delays in care and notify the appropriate staff to best reduce these occurrences.
The Utilization Review Nurse will document and communicate findings with the care team and the payor, when necessary, and track data for reporting at the Utilization Review Committee.
ResponsibilitiesUtilization Review:
Case Management:
Manager of Care Transitions professionals in Manchester
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mike J
Vice President of Operations
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Natalie Lopez
Physician Assistant Student