Utilization Review Care Manager

Evaluations

Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information and InterQual guidelines.

Documentation and Communication

• Serves as liaison between physicians, patients, payers, and care managers regarding termination of benefits, denial notifications, and expedited appeals.
• Serves as a resource for staff and physicians about managed care principles, observation status, discharge planning, and reimbursement rules.
• Verifies patient admission information for each assigned patient within 24 hours of patient's admission (next business day).
• Negotiates resolution disagreements over the need for acute hospital level of care with the insurer.
• Collaborates with social workers for patients with complex, clinical, financial, and psycho-social needs.
• Reviews physician orders and patient progression and intervenes with care coordination as needed.
• Collaborates with other departments to eliminate barriers, as necessary.
• Builds trusting relationships with attending physicians, patients, and/or families and other members of the healthcare team.
• Establishes a caring relationship with patients and their caregivers, promotes patient engagement, and guides patients/families through the transition phase.

Quality and Risk Management

• Identifies and reports Quality and Risk Management concerns.
• Maintains performance, patient, and employee satisfaction and financial standards as outlined in the performance evaluation.
• Maintains performance, patient, and employee satisfaction and financial standards as outlined in the performance evaluation.

Supporting Clinical Documentation

• Updates and documents in Midas, pertinent clinical information by utilizing screening criteria and assigns next review date.
• Supports and participates in department strategies and efforts focused on improving length of stay (LOS) and reduction of avoidable readmissions.
• Supports and participates in department strategies and efforts focused on improving clinical documentation by physicians.

Other Duties

• Supports and participates in department strategies and efforts focused on improving clinical documentation by physicians.
• Supports and participates in department strategies and efforts focused on improving length of stay (LOS) and reduction of avoidable readmissions.
• Supports and participates in department strategies and efforts focused on improving clinical documentation by physicians.

Qualifications

• Minimum of Registered Nurse with current Alabama license.
• Minimum of 2 years experience as an RN.
• Minimum of 2 years as care management and/or utilization management experience preferred.
• Minimum of 2 years of Med Surgical experience required; Utilization Review experience preferred.

Physical Requirements

• Requires Light work. Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.
• Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.
• Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.

Work Environment

• Ability to form positive, collaborative relationships with physicians, colleagues, hospital staff, patients, families, and external contacts.
• Ability to provide guidance and direction to subordinates, including performance standards and monitoring performance.
• Ability to encourage and build mutual trust, respect, and cooperation among team members.
• Ability to communicate with people outside the organization and represent the organization to the public, government, and other external sources.
• Ability to work independently or within a team structure.
• May be exposed to environmental cleaning chemicals.