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.
• Collaborates with business office, care managers, attending physicians, and physician advisors as needed.
• Verifies patient admission information for each assigned patient within 24 hours of patient’s admission (next business day).
• Collaborates with the Case Manager to identify referrals to Financial Counselors.
• 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.
• Builds trusting relationships with attending physician, patient and/or family 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.
• Maintains records in a complete, detailed, and orderly manner.
• Updates and documents in Midas, pertinent clinical information by utilizing screening criteria and assigns next review date.

Education and Training

• Works with Patient Registration\Financial Counselor(s) to identify correct insurance source and proper billing.
• Collaborates with other departments to eliminate barriers, as necessary.
• Provides education to staff and physicians about managed care principles, observation status, discharge planning, and reimbursement rules.
• Reviews physician orders and patient progression and intervenes with care coordination as needed.
• Collaborates with the Case Manager to identify referrals to Financial Counselors.
• 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.
• Builds trusting relationships with attending physician, patient and/or family 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.
• Maintains records in a complete, detailed, and orderly manner.
• Updates and documents in Midas, pertinent clinical information by utilizing screening criteria and assigns next review date.

Quality and Risk Management

• Identifies and reports Quality and Risk Management concerns.
• Identifies potential avoidable days per department policy.
• Gathers information for statistical monitors, plus special projects within the Care Management Department.
• Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
• Performs compliance requirements as outlined in the Employee Handbook.

Other Duties

• 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.
• Keeps abreast of hospital mission, vision, and values and performs in a manner to support them.
• Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
• Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
• Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
• Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
• Requires use of electronic mail, time and attendance software, learning management software and intranet.
• Must adhere to all DCH Health System policies and procedures.
• Performs other duties as assigned.

Qualifications

• Minimum of Registered Nurse with current Alabama license.
• Minimum of 2 years experience as an RN.
• Minimum of at least 2 years as care management and/or utilization management experience preferred.
• Minimum of 2 years of Med Surgical experience required; Utilization Review experience preferred.
• Must be able to read, write legibly, speak, and comprehend English.
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