ED UTILIZATION REVIEW/CASE MANAGER

Duties and Responsibilities

• 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
• Collections 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
• Solves 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
• Aids 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
• P Practices, develops and endorses customer services skills in relationships with internal and external customers
• Provides 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

Additional Duties and Responsibilities

• 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

Knowledge, Skills, and Abilities

• 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

Benefits

• Paid Sick Time - effective 90 days after employment
• Paid Vacation Time - effective 90 days after employment
• Health, vision & dental benefits - eligible at 30 days, following the 1st of the following month
• Short and long-term disability and basic life insurance - after 30 days of employment

Insight is an equal opportunity employer and values workplace diversity!