Utilization Management Coordinator, Inpatient

Utilization Management Coordinator, Inpatient

Job Summary: The Utilization Management Coordinator, Inpatient (UMC) serves an important role in supporting Cook County Health (CCH) goals of efficient, effective, patient-centric care. Using the electronic medical record (EMR) and consulting with the treatment team, the UMC determines if the patient is in the appropriate level of care and if clinical milestones are being met in a timely manner. The UMC provides timely feedback to the treatment team and makes appropriate referrals to other care coordination components for those patients who have barriers to discharge or whose condition requires a different level of care. The successful UMC has a sound clinical foundation, knowledge of utilization management, and critical thinking skills to support effective, timely communication regarding case status.

Typical Duties:

• Verifies payer status and medical home (documents same in notes)
• Reviews cases being proposed for inpatient or observation at Stroger and Provident Hospitals within one hour of notification.
• Provides continued stay review at intervals appropriate to the treatment plan and anticipated patient progress.
• Review reflects the ability to: Translate signs, symptoms, lab values, diagnostic testing results, to a MCG guideline. For example, the UMC is able to discern the origin of shortness of breath based on history, clinical presentation, vital signs and test results to select the appropriate guidelines Document all relevant information in case notes Detects and documents trends and in clinical and functional status data to assess patient progress
• Correctly assigns medical necessity determination and level of care. If different than current assignment, notifies treatment team to alert them and provides recommendations.
• Identifies and refers cases at risk: Readmissions within thirty (30) days Failure to meet guidelines (either on initial or concurrent review) Multiple social determinants impacting care or treatment Active MH or SUD Those requiring on-going care coordination Complex treatment plans Managed Care Required care coordination Planned re-admission requiring pre-certification
• Uses portals to forward clinical information to payers
• Communicates succinctly and efficiently with stakeholders such as insurance companies, physicians, Inpatient Care Coordination Specialist,
• Monitors the process of obtaining pre-certifications and prior authorizations from insurance providers and third-party payers to ensure coverage for services.
• Escalates cases when EMR documentation doesn't support medical necessity requirement and outreach has not closed gaps.
• Identifies and reports potential denial or delays in care to the Inpatient Care Coordination Manager
• Supports and organizes peer-to-peer conversations to avoid potential denials.
• Participates in departmental quality improvement guidelines
• Completes all educational efforts for CCH and licensure
• Conducts reviews of medical records to determine the medical necessity and appropriateness of admissions, continued stays, procedures, and discharge plans, using established guidelines like InterQual or MCG.
• Verifies coverage for post-acute services (home health, rehab, DME)
• Completes a minimum of forty-two (42) reviews per day (initial admissions and continued stay admissions)

Minimum Qualifications: Current License as a Registered Professional Nurse in the State of Illinois, is required. Bachelor's Degree in Nursing from an accredited college or university, is required. Minimum of three (3) years of acute care, medical surgical, and/or clinical experience as a registered nurse, is required. Minimum one (1) year of experience in utilization management or clinical case management, is required. Successful completion of an MCG Health Certification exam prior to starting employment, is required.

Preferred Qualifications: Masters degree in Nursing from accredited college or university, is preferred.

Knowledge, Skills, Abilities and Other Characteristics:

• Knowledge of UM evidence-based practices, clinical practice guidelines, medical necessity criteria, and case management
• Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age group
• Demonstrated problem solving skills
• Ability to adjust work pace to review demands
• Excellent interpersonal skills, maintains demeanor
• Ability to succinctly and accurately communicate case issues to relevant stake holders in a non-judgmental manner
• Ability to prioritize work
• Leverages technology to improve work flow

Physical and Environmental Demands: This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements. This includes but is not limited to the following policies and procedures: complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.

Benefits Package: Medical, Dental, and Vision Coverage Basic Term Life Insurance Pension Plan and Deferred Compensation Program Employee Assistance Program Paid Holidays, Vacation, and Sick Time 100% Tuition Reimbursement for nursing-related programs

Veteran Preference: When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service. To take advantage of this preference a Veteran must: Meet the minimum qualifications for the position. Identify self as a Veteran on the employment application by answering yes to the question, "Are you a Military Veteran?" Attach a copy of their DD 214, DD 215 or NGB 22 (Notice of Separation at time of application filing. Please note: If you have multiple DD214s, 215s, or NGB 22S, Please submit the one with the latest date. Coast Guard must submit a certified copy of the military separation from either the Department of Transportation (Before 9/11) or the Department of Homeland Security (After 9/11). Discharge papers must list an Honorable Discharge Status. Discharge papers not listing an Honorable Discharge Status are not acceptable OR A copy of a valid State ID Card or Driver's License which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing. If items are not attached, you will not be eligible for Veteran Preference. Veterans must provide original applicable discharge papers or applicable state ID card or driver's license at time of interview. Must meet all required qualifications at time of application filing.

Cook County Health and Hospitals System is an equal opportunity employer.