UR Review Case Manager (Admin)

UR Review Case Manager (Admin)

The Utilization Review/Case Manager is responsible for facilitating the appropriate use of hospital resources by ensuring that the patient meets acute inpatient criteria, and anticipates and provides assistance with discharge needs in a timely fashion. This position is a central communicator with external and internal customers, including vendors, payers, community agencies, patients, families, hospital staff and departmental personnel. The position collaborates with social workers and case managers for discharge planning and utilization review activities. This individual supports the functions of the department with efficient office management of the department by answering phones, ordering supplies, typing/computer entry, tracking and compiling data.

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.

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.

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.

Graduate of an accredited school of nursing required. Current RN License in the State of Illinois required. Two years of relevant clinical experience preferred.