To maintain high-quality, medically necessary, evidence-based care, and efficient treatment of all patients, regardless of payment source, by ensuring the patients receive the right care, at the right time, in the right place.
Case Management Model: utilize an Integrated Case Management Model. Under this model the Case Managers will follow patients through the continuum while facilitating the functions of utilization review, utilization management, and cost containment. Track and trend denials and payor issues to provide feedback and education to payer relations and the case management department.
Clinical review of 100% acute bedded patients admitted to Inpatient or Observation status at The Christ Hospital against medical necessity criteria (Interqual and MCG) for appropriateness of admission.
Demonstrate understanding of evidenced based medical necessity criteria. Maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions.
Identify/facilitate patient status from observation to inpatient as patient clinical condition warrants.
Compliance with all Medicare regulatory requirements
Work with external payers completing/securing authorization for all services provided.
Monitors cases for appropriateness of continued stay, level of care and services, and quality of care using approved screening criteria. Communicate with physicians when alternatives to inpatient care are indicated by clinical review.
Identify cases needed for second level of review- refers cases to the Physician Advisor that do not meet established guidelines for admission or continued stay.
Consistent collaboration with the RN Case Manager to prevent extended length of stays and appropriate status determination.
Identifies potential delays in service or treatment and refers to the appropriate individuals within the multidisciplinary patient care teams for action/resolution.
Track and trends avoidable day information in Midas per process.
Identifies problems related to the quality of patient care and refers such problems to the Performance Improvement Department.
Adherence to department productivity standards. Initial, concurrent, and retro reviews should be completed timely including all necessary information for approval of claims. All reviews should contain information only pertinent to IS/SI (Intensity of Service/Severity of Illness).
Compliance with documentation methods for monthly reporting and statistics for presentation to the Utilization Review Committee.
Interfaces with patient registration and patient financial services etc. to collaborate on financial issues.
Establish an effective rapport and relationship with third party payers to promote cost effective clinical outcomes.
Assist in denial and appeal process
Performs other duties as assigned, including but not limited to:
• Demonstrates professional responsibility required for a Utilization Review Nurse
• Complies with department and hospital policies at all times
• Maintains compliance with State/Federal Guidelines and standards
• Conforms to all requirements of Medicare
• Keep current on changing laws and requirements of Medicare
• Demonstrate a positive attitude at all times
KNOWLEDGE AND SKILLS:
Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.
EDUCATION: Bachelor’s Degree. Graduate of an accredited school of nursing with current licensure OR actively enrolled in a BSN program with completion date within 3 years of hire date and a graduate of an accredited school of nursing with current licensure.
YEARS OF EXPERIENCE: 3-5 years of medical/surgical nursing necessary and a minimum of 3 years of utilization review experience required.
REQUIRED SKILLS AND KNOWLEDGE:
Experience with case management, utilization review, and discharge planning that is related to the clinical or operational functional areas.
- Knowledge and application of a wide variety of advanced case management tools and methods.
- Knowledge of clinical and operations research methodology and design. Proficient in state of the art business trends, benchmarking, and case management tools and techniques.
- Ability to operate PC based software programs or automated database management systems.
- Expertise in meeting regulatory and accreditation requirements.
- Strong presentation, written and oral communication skills, with strong analytical and problem-solving skills as well as time/project management skills.
Ability to work with a variety of disciplines and levels of staff across departments and the organization is required.
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LICENSES & CERTIFICATIONS:
Licensed to practice in the State of Ohio
Certified Case Management (CCM) or Accredited Case Management (ACM) preferred.
