Utilization Manager (RN)

Utilization Manager

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Summary: The Utilization Manager (UM) assesses new admissions, continued stay and discharge review cases for medical necessity, appropriate class and level of care (LOC). This position works collaboratively with an interdisciplinary team (including physicians, other care providers, payers, etc.) to ensure the patient's needs are met and care delivery is coordinated. The UM completes utilization reviews in accordance with federal regulations and the health system's Utilization Review Plan.

Responsibilities:

• Uses approved criteria and conducts admission review/class change review as trigger by patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identifies and obtains observation services as appropriate. Partners with physicians, nursing, and other care providers to help ensure timely and accurate documentation of patient data and treatments. Communicates daily with the Care Manager to manage level of care transitions & appropriate utilization of services. Coordinates with the appropriate staff/payers to assure third party payer pre-certification and/or re-certifications when required. Discharge Facilitation: Utilizes high risk screening criteria to make appropriate referrals. Identifies patient/families with the complex psychosocial, on-going medical transition planning issues, continuing care needs by initiating appropriate care management referrals. Initiates appropriate social work referrals.
• Performs utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients as appropriate to ensure optimal patient outcomes. Using approved criteria, conducts initial and continued stay reviews to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality-driven, efficient, and effective. Enters all pertinent review data into the correct computer system in a timely manner. Consults with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels.
• Monitors and guides to trend interdisciplinary documentation and guides medical staff in documentation that will assist in coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitates patient movement to appropriate (acuity) level of care including observation services issues through collaboration with patient/patient representative, multidisciplinary team, third party payers and care managers/social workers. Provides information regarding denials and approvals to appropriate staff and/or designated entities. Documents and delivers notifications to patients, patient representative and/or appropriate staff. Reviews Pre-Scheduled surgery admissions for proper status order for inpatient-only procedures.
• Collaborates to problem-solve issues with complex patients and identify trends. Formulates potential solutions with Care Manager and Social Worker and continuously monitors cases/follows up on all action items. Proactively identify high risk cases that need to be escalated to the list that are not scheduled for discussion that week.

Required:

• Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states.
• Two (2) years of experience working as a Registered Nurse.
• Strong verbal and written communication.
• Basic Life Support (BLS) certification.

Preferred:

• Bachelor's of Science in Nursing (BSN)
• Certification in Case Management