RN Case Manager - Utilization Review

Key Responsibilities

• Provides leadership and advocacy in the coordination of patient-centered care across the continuum to facilitate optimal transitions and progression in care.
• Conduct concurrent and retrospective reviews of patient medical records to verify the medical necessity of services provided.
• Assess admission criteria and length of stay, applying standardized clinical guidelines such as InterQual or MCG to justify care levels.
• Issue pre-authorizations for procedures, medications, and durable medical equipment by providing clinical information to insurance carriers.
• Collaborate with physicians and other healthcare providers to discuss patient care plans and ensure alignment with coverage policies.
• Facilitate communication between medical staff and payers to resolve issues related to treatment plans and reimbursement.
• Identify and refer cases to case management or social work for complex discharge planning needs.
• Prepare and submit clinical appeals to insurance companies when services are denied, providing documentation to support medical necessity.
• Track and analyze utilization data to identify trends in resource use, care delays, and claim denials for reporting purposes.

Education

• Associate Degree in Nursing (ADN) required
• Bachelor of Science in Nursing (BSN) preferred

Experience

• Three to five years of clinical experience in a direct patient care setting within an acute care hospital required
• Previous experience in case management or utilization management required

Requirements

• A current and unrestricted Arizona Registered Nurse (RN) license
• Certification in Health Care Quality and Management (HCQM) or as a Certified Case Manager (CCM) credential preferred

Knowledge

• Medical Necessity Analysis: Detailed evaluation of patient medical records to determine if proposed treatments, procedures, and services are medically appropriate and necessary according to established standards.
• Payer-Provider Liaison: Effective communication between healthcare providers and insurance payers to resolve discrepancies and pre-emptively address potential denials.
• Utilization Data Interpretation: Collaboration with the Revenue Cycle Management (RCM) team to analyze utilization data to spot trends, such as patterns in claim denials, delays in care, or inefficient use of resources.

Skills

• Patient Assessment: Comprehensive assessment of patients' medical, emotional, and social needs to develop individualized discharge plans that ensure continuity of care.
• Care Coordination: Collaboration with healthcare providers, including doctors, nurses, and therapists, to create an integrated plan of care that addresses clinical needs, equipment, home care, and other requirements.
• Discharge Planning: Determining the appropriate discharge disposition based on factors such as living situation, mobility, cognitive status, and available support systems.
• Arranging Services: Coordinating necessary post-discharge services, such as home health care, rehabilitation, and durable medical equipment, ensuring they are in place before the patient leaves the hospital.
• Communication: Maintaining clear communication with all parties involved in the patient's care, including insurance providers, to secure coverage for post-discharge services and ensure that receiving providers are informed of the patient's needs and changes in their condition.
• Clinical Guideline Application: Applying standardized clinical criteria, such as InterQual or MCG, to objectively justify admission, continued stays, and the appropriate level of care.

Abilities

• Ability to work in a high-stress, fast-paced environment
• Ability to develop relationships with providers, staff, patients, families, and payors
• Ability to work cooperatively and professionally in a team environment