Case Manager/Utilization Review - Flex

About the role

The Case Manager/Utilization Review assumes responsibility for assessing and directing the clinical management of patients in specific case groups for an episode of care. The CM/UR is responsible for developing and meeting desired patient care outcomes for his/her caseload based on assessment of patient care needs and on established clinical care patterns, within an appropriate length of stay and appropriate use of resources.

Responsibilities

• Conducts initial screening and assessment of patients on admission including twenty-hour observations using pre-established Intensity of Service and Severity of Illness criteria.
• Determines diagnosis related group (DRG) and appropriate length of stay (LOS) based on admission screening.
• In collaboration with physicians and other health care professionals, plan, organize, direct, and evaluate the continuum of patient care.
• Evaluates interventions of physicians and other health care disciplines based on care pathways, severity of illness, and intensity of service criteria.
• Serves as a coordinator, negotiator, procurer, and manager of the plan of care to facilitate cost effective quality of care and patient satisfaction.
• Identifies and reports any quality, risk management, or utilization issues to the Director of Case Management.
• Facilitates and coordinates patient care team conferences.
• Communicates utilization issues, discharge planning reviews, and variances of care.
• Completes monthly statistical log to reflect case activity.
• Assists the Director of Case Management in the investigation of over and underutilization cases, implementation of corrective measures, and chart review per medical staff request.

Requirements

• High School Diploma or GED required.
• Minimum of two years’ experience in Medical/Surgical, Psychiatry and/or Critical Care.
• At least one to two years progressive experience in utilization management, discharge planning, or case management.
• Strong communication skills, utilizes problem-solving process, acts as a team leader, demonstrates good work ethic, demonstrates good nursing assessment skills, maintains confidentiality, demonstrates flexibility and analytical skills.
• Has working knowledge of resources available in the community for the patient and families.
• Has basic knowledge of criteria sets.
• Demonstrates working knowledge of payer requirements.

Qualifications

• High School Diploma or GED required.
• Minimum of two years’ experience in Medical/Surgical, Psychiatry and/or Critical Care.
• At least one to two years progressive experience in utilization management, discharge planning, or case management.
• Strong communication skills, utilizes problem-solving process, acts as a team leader, demonstrates good work ethic, demonstrates good nursing assessment skills, maintains confidentiality, demonstrates flexibility and analytical skills.
• Has working knowledge of resources available in the community for the patient and families.
• Has basic knowledge of criteria sets.
• Demonstrates working knowledge of payer requirements.

Skills

• Understanding of payer requirements.
• Knowledge of resources available in the community for the patient and families.
• Basic knowledge of criteria sets.

Benefits

N/A

Pay

N/A

Schedule

N/A