Utilization Review Case Manager -Registered Nurse

Duties

• Identifies patients at risk for encountering problems post-hospitalization through performing a comprehensive assessment of patient discharge needs and assists to facilitate a referral for appropriate discipline/team members and outside agencies for facilitating safe and appropriate discharge plan.
• Identification of community resources and coordination of referral.
• Prioritize and manage daily workload, including analyzing and evaluating daily assigned caseload and prioritizing patients requiring discharge assessment, readmission risk assessment, or discharge plan.
• Assure timely and appropriate documentation of discharge and risk assessments, discharge plan, utilization management, and follow-up care to assure safe and cost-efficient continuity of care.
• Works with patient and interdisciplinary care team members to coordinate and implement patient discharge planning.
• May collaborate with community resources and be a liaison between Care Management and agencies as appropriate for the benefit of discharge planning.
• Communicates patient discharge plan with appropriate stakeholders.
• Documents clearly all assessments, interventions, and planning in a clear, concise, accurate, and timely manner.
• May perform initial and concurrent medical record review for third party payers.
• May review medical records for medical necessity of hospital admission and continued stay using Interqual or other assigned guidelines.
• Educate and include patient and family in transition planning in preparation for discharge and provides updates and/or changes throughout the hospital stay.
• Contact and arrange placements to skilled nursing facilities, rehab, long-term care, specialty care, home health agencies.
• Other duties as assigned dependent upon training and scope of practice.
• Utilization Review
• Works in collaboration with Physician Advisor and commercial payors to perform prospective, concurrent, and retrospective reviews to determine if patient level of care is determined to be medically necessary.
• Performs Risk Assessment for all new admissions to determine need for assignment to Discharge Planning for a comprehensive face-to-face patient assessment to identify and plan for appropriate discharge plan.

Skills/Qualifications

• Strong verbal, written, and interpersonal communication skills.
• Strong organization skills with the ability to work independently or as part of an interdisciplinary team in a fast-paced environment.
• A high level of maturity, professionalism, and discretion in daily interactions with patients, families, and interdisciplinary team.
• Timely and effective communication with patients, families, providers, and interdisciplinary team.
• Assure excellent customer service is provided to all stakeholders inside and outside the organization.
• Knowledge of discharge planning, utilization review, CMS criteria related to patient status, and general payor reimbursement requirements.
• Strong analysis/problem-solving skills.
• Computer skills to include proficiency in keyboarding and data entry.
• Critical thinking skills, able to assess, evaluate, and teach.
• MS Office proficiency preferred.

Requirements

• Minimum of three (3) years’ experience in a hospital setting with medical/surgical experience; may have equivalent combination of education and/or experience.
• One (1) year experience in discharge planning, case management, and/or utilization management experience.
• Maintain active RN license issued by the WA Department of Health.
• Graduate of an accredited school of nursing; advanced education to include BSN preferred.