Utilization Review Case Manager (45966)

Under general supervision of the PRC Nurse Manager, the Utilization Review RN Case Manager will work independently in conjunction with the multidisciplinary team members involved in the care of patients at Dilkon Medical Center. The focus will be on case management, utilization review, discharge planning, facilitating smooth patient care transitions and ensuring compliance with regulatory standards. The Utilization Review RN Case Manager will provide comprehensive support within the hospital environment by collaborating with a diverse range of clinical staff, including nurses, social workers, physicians, multidisciplinary teams, and family members. Must possess a thorough understanding of current regulatory compliance requirements related to Government Payers and vendors, specifically concerning Admission Status, Clinical Documentation, and Value-Based Purchasing. Upholds the principles of WIHCC's Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Maintains regular attendance and punctuality.
• Conduct thorough prospective, concurrent, and retrospective medical reviews for managed care members.
• Collaborate with clinical providers to assess admission status and reviews for continued stay.
• Communicate effectively and compassionately with patients, families, and providers, ensuring timely updates and collaboration.
• Present findings to the medical management committee and convey outcomes clearly and concisely.
• Assess patients' physical, functional, social, psychological, and financial needs to create a holistic understanding of their care requirements.
• Develop and implement individualized care plans, prioritizing goals based on patient and caregiver preferences.
• Continuously monitor care plans for effectiveness and appropriateness of services provided.
• Assists in coordinating and tracking referrals in conjunction with WIHCC, Inc providers and outside specialists, and collaborates closely with the Inpatient and Outpatient RN Case Managers.
• Provide education and support related to patient care goals and resources.
• Function as a patient advocate, addressing barriers to care and facilitating access to community and cultural resources.
• Stay informed about medical policies and coverage guidelines relevant to position to ensure compliance and quality care.
• Monitor quality and compliance measures using chart audits.
• Maintain accurate and confidential patient records in accordance with documentation standards and regulations.
• Assist with workflow stabilization during high-volume periods.
• Maintains strict confidential policies complying with HIPAA and WIHCC policies due to the sensitive nature of patient information.
• Upholds all principles of confidentiality and patient care to the fullest extent.
• Adheres to all professional and ethical behavior standards of the healthcare industry.
• Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
• Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
• Possesses cultural awareness and sensitivity.
• Maintains compliance with all Human Resources requirements.
• Performs other duties as assigned.

Minimum Qualifications:

Bachelors' degree in Nursing required, Masters' degree in Nursing or related field preferred. At least one (1) year experience in case management and utilization review is essential. Advanced nursing experience preferred, certifications as a Certified Case Manager (CCM or ACM) required. Bilingual skills in English and Navajo language preferred. Must maintain a valid unrestricted and insurable driver's license. Must successfully pass a background investigation and maintain suitable requirements for a Child Care position. This position is considered as a Child Care position, which requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).

Knowledge, Skills, Ability

• Knowledge of strong work ethics in the workplace.
• Knowledge of basic application of confidentiality.
• Knowledge of basic computer skills, e.g. Outlook, Word, Excel, PowerPoint.
• Knowledgeable in EHR systems, Microsoft Office, excel and data management.
• Knowledge of Managed Care as it relates to contracting in health care, DRG's CPT and ICD-10 coding.
• Ability to maintain and adhere to confidentiality of medical information and guidelines in accordance with the Privacy Act, HIPAA, HITECH, TJC, EMTALA and OSHA rules and regulations.
• Ability to be dependable in attendance and job performance.
• Ability to meet attendance, overtime (if necessary), and other reliability requirements of the job.
• Ability to accept and learn from feedback.
• Ability to rotate between modalities as operational needs shift.
• Ability to recognize workflow inefficiencies and escalate appropriately.
• Ability to communicate effectively both verbally and in writing.
• Ability to provide exemplary customer service at all times.
• Ability to interact positively with others and possess great interpersonal skills.
• Ability to multitask and perform well under pressure.
• Ability to have self-confidence.
• Ability to be a great team player.
• Ability to accept and learn from supervisor/peer critique.
• Ability to be flexible and adaptable to the changing needs of the organization.

Physical Demands:

While performing the essential functions of this position, the employee is regularly required to walk, sit, use hands and fingers, handle, or feel objects and equipment, reach with hands and arms, and communicate effectively by talking and hearing. The employee frequently must stand, climb, balance, stoop, kneel, crouch, or crawl and may occasionally use taste or smell. The employee must occasionally lift and/or move objects weighing up to 50 pounds.


Work Environment:

Work is performed in an office setting or outdoor work environment with moderate noise levels. Work environment may involve exposure to physical risks, such as blood borne pathogens, hazardous chemicals, or operating potential dangerous equipment, and requires adherence to all safety protocols. Required work schedules may include evening, weekend, overnight shifts, extended hours, or irregular schedules as operational needs dictate.


As required by P.L. 93-638, absolute preference will be given to qualified Navajo applicants. If there is no qualified Navajo applicant, preference will be given to qualified American Indian applicants.