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Accountable for performing initial, concurrent, or post service review activities; discharge care coordination; and assisting with efficiency and quality assurance of medical necessity reviews in alignment with Federal, State, Plan, and Accreditation standards. The UM reviewer serves as a liaison between providers/ facilities and Care Management Division.
Supports the Collaborative Care Management Model as a working partner with physicians, social workers, pharmacists and other professional staff.
Demonstrates proficiency in the application of National clinical case review criteria and appropriate levels of care across the care continuum for managing complex cases and related episodic care events.
Demonstrates proficiency with caseload assignment and ability to manage complex cases effectively.
Demonstrates an understanding of funding resources, services and clinical standards and outcomes.
Demonstrates knowledge of case management standards of practice and processes including identification and assessment, planning, interventions and evaluation.
Demonstrates a solid understanding of managed care trends, Medicare, and Medicaid regulations, reimbursement and the effect on utilization and outcomes of the different methods of reimbursement
Demonstrates the ability to develop departmental interfaces with internal and external customers to provide exemplary service and achieve goals.
Demonstrates participation in multi-disciplinary team rounds if designated to cover a facility designed to address utilization/resource and progression of care issues.Assists in developing and implement an improvement plan to address issues.
Develop discharge plan in coordination with and act as a resource to the facility Care Manager and Discharge Planner.
Implement discharge plan to prevent avoidable days or delays in discharge.
Transition patient to next level of care in coordination with facility Discharge Planner.
Re-certify appropriate post-acute care.
Identify and refer complex risk members to case management.
Complete documentation completely and accurately in accordance with:(a) eligibility and benefits (b) clinical guidelines/criteria (c) legal and regulatory requirements.
Identify documents and refer cases to the UM Team Leader for medical review when services do not meet medical necessity criteria and/or appropriate level of care.
Identify and refer cases to the UM Team Leader for potential quality indicators.
Maintains objectivity in decision making, utilizing facts to support decisions.
Supports the mission statement, policies and procedures of the organization.
Assists in eliminating boundaries to achieve integrated, efficient and quality service
Achieves ongoing compliance with all regulatory agencies
Serves as a resource to employees and customers as demonstrated by visibility and knowledge of issues.
Reviews and adheres to department policies and the Utilization Management Plan and Case Management program specific requirements.
Completes interdepartmental education
Accurately applies decision support criteria
Utilizes resources efficiently and effectively
Maintains safe environment
Participates in Performance Improvement activities
Graduate of an accredited School of Nursing, RN
Bachelors or Masters' Degree in Nursing
3 years utilization management experience in an acute or post-acute provider, health plan or other care company experience
Minimum of 2 years' experience in direct patient care as an RN, preferred acute care (ER, ICU, or Medical/ Surgical)Knowledge of specific regulatory, managed care requirements, and strong attention to detail.
Working knowledge of computers and basic software applications used in job functions such as word processing, graphics, databases, spreadsheets, etc.
5 years' experience in Health Plan Utilization Review, Discharge Planning and Medical Case Management.
Experience and knowledge of Milliman Guidelines or similar clinical guidelines.
Strong analytical and organizational skills.Working knowledge and ability to apply professional standards of practice in work environment.
Possession of current Registered Nurse license in state of hire.
The above job description is not intended to be an exhaustive list of all responsibilities, duties, and skills required of the job. Management retains the right to add or to change the duties of the positions at any time with or without notice.
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