UR Review Case Manager-RN

Duties and Responsibilities:

• Performs inpatient utilization management activities as determined by the utilization plan, professional standards and requirements of payers:

• Works collaboratively with physicians and other healthcare team members to effect timely and appropriate patient management on an ongoing basis.

• Collects data as required to support necessity of admission and continued hospitalization based on department standards.

• Supports the DRG (Diagnosis Related Group) Assurance Program through data collection and ensures that the DRG worksheets contain complete and accurate information and appropriate DRG assignment.

• Provides accurate clinical information to payers as required.

• Resolves system problems impeding diagnostic or treatment progress such as delays in the discharge process.

• Performs non-acute profiling, collecting data on avoidable days and physician advisor referral codes.

• Assists in the division of Patient Care Services staff in facilitating the safe discharge of patients:

• Participates in family meetings and care conferences as needed to resolve identified issues.

• Ensures timely referrals for discharge planning occur and regional/community resources are utilized when available.

• Refers complex cases to Social Services as indicated.

• Uses clinical and social work experts as needed to ensure delivery of comprehensive patient services.

• Ensures the patient’s psychological needs are met through direct intervention or consultation with appropriate discipline.

• Interacts regularly with physicians and other members of the health team to obtain information about the course of care; provides information in return regarding potential denial of reimbursement or inappropriate level of care:

• Refers cases not meeting criteria in a timely manner to the physician advisor.

• Determines need for and carries out termination of benefits and level of care changes based upon department procedures and maintaining responsibility for related communication and follow-up.

• Follows up with Medical Director/Physician Advisor to determine outcome or resolution.

• Central communicator with external and internal customers:

• Practices, develops and endorses customer services skills in relationships with internal and external customers.

• Provide continuity of care by using community resources and maintains updated resource manual for the department

• Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered.

• Collaborates with multidisciplinary team in facilitating the care of the patients and families within the acute setting and along the healthcare continuum.

• Attends in-service presentations and completes all mandatory education requirements.

Additional Duties and Responsibilities:

• Maintains a safe patient care environment by identifying potential safety hazards and intervening appropriately.

• Operates and maintains equipment used in patient care in a safe manner.

• Understands and follows infection control requirements in the care of patients.

• Maintains awareness of hospital changes by reading posted notices, attachments to paychecks and attending scheduled staff meetings.

• Performs all other duties as assigned.

Knowledge, Skills, and Abilities:

• Graduate of an accredited school of nursing required.

• Current RN License in the State of Illinois required.

• Two years of relevant clinical experience preferred.

• Previous utilization management experience preferred.

• Knowledge of Medicare/Medicaid, Managed Care and Commercial insurance review processes preferred.

• Ability to proactively anticipate and coordinate multiple functions to promote an optimal office environment.

• Communicates clearly in written and oral modalities with appropriate grammar and vocabulary.

• Proficient in Microsoft Word and Excel required.

• Ability to provide excellent customer service at all times.

Benefits:

• Paid Sick Time - effective 90 days after employment

• Paid Vacation Time - effective 90 days after employment

• Health, vision & dental benefits - eligible at 30 days, following the 1st of the following month

• Short and long-term disability and basic life insurance - after 30 days of employment