Utilization Care Manager

Summary:

Reports to the Director of Care Management or designee. Conducts surveillance over medical necessity of patient care records. In collaboration with the physician of record and the Utilization Review Committee physician ensures the appropriate level of patient care is provided and that admission and concurrent authorizations from third party payers are obtained. Ensures appropriate and timely utilization of resources and services so that patients receive high quality safe and fiscally responsible care.

Responsibilities:

Demonstrates a fundamental grounding in nursing theory and practice with a clinical background within a defined content area. Remains current on the latest concepts techniques and methods relative to his/her service.Demonstrates knowledge of federal and state rules and regulations. Applies InterQuallevel of care screening criteria to all admissions within one business day of admission. Interacts with team and physicians to resolve any level of care discrepancies and ensures accurate documentation. Discusses with attending of record when patient level of care criteria is not met to discuss a plan of action.Reviews all admissions and proactively provides clinical information to third party payers to support level of care. Serves as a liaison with third party payers as necessary to clarify level of care questions. Reviews all Medicare patient admissions daily and ensures the appropriate level of care for patients per Medicare and insurance regulatory guidelines. Conducts concurrent reviews on all patients at a minimum of every three days to facilitate patient throughput during current episode of care and to identify delays. Delivers Hospital Issued Notice of Non-coverage (HINN) to Medicare Beneficiaries when acute inpatient admission is not medically necessary or could be furnished in an alternative setting. Initiates and completes concurrent expedited patient appeals and advises patients of insurersresponse provides guidance and counsel on the appeal process and their care options. Provides education to members of the healthcare team regarding Medicare and regulatory guidelines regarding appropriate levels of care the HINN delivery and the patient appeal process.Acts as a liaison with the Care Coordination Manager to discuss approaching discharge readiness of patients. Reviews and acts as a change agent by identifying opportunities to improve patient flow and identifies and reduces service delays through problem resolution and follow-up. Identifies and tracks service and discharge patient delays.Promotes patient satisfaction by proactively providing clinical information to third party payers to ensure authorization for hospital services and conducting expedited appeals of denied services in collaboration with the patients physician of record.Emergency Department Utilization Care Manager ensures the appropriate level of care is assigned to patients upon admission. Responsible for the identification of Medicare Beneficiaries that require Hospital Issued Notices of Non Coverage (HINN). Responsible for delivery of appropriate notices as indicated and advises patient of appeal rights and care options.

Other information:

Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.

BASIC KNOWLEDGE:Bachelors degree in Nursing with current license to practice as a Registered Nurse in the State of Rhode Island. Masters Degree preferred.Certified Professional in Healthcare Management (CPHM) is highly desirableEXPERIENCE:Five yearsclinical experience with recent experience in utilization review case management patient navigation or discharge planning is strongly preferred. Strong analytical and interpersonal skills are required to provide guidance to and communicate daily with healthcare professionals patients and families. Must exhibit a collaborative approach and method of communication in order to interact successfully on as daily basis with a wide and diverse population of both health care providers insurers patients and their families.Familiarity with InterQualcare management criteria is required as well as a high level of knowledge concerning utilization review healthcare finance and the requirements of relevant payers.Demonstrates knowledge and skills necessary to provide care to patients throughout the life span with consideration of aging processes human development stages and cultural patterns in each step of the care process. Must be proficient in the use of Microsoft Office software including email and Outlook calendar and have basic keyboarding skills. WORK ENVIRONMENT AND PHYSICAL REQUIREMENTS:General hospital environment with occasional stressful conditions associated with patient care. Risk of exposure to blood borne pathogens and disease is minimized and controlled by adherence to Hospital Infection Control policy and procedures.Must be able to make hospital rounds through various patient care areas either by walking or through some other mobile means. Visual acuity and finger dexterity is needed to review and carry medical records navigate through automated system screens and type on a typical computer terminal keyboard. Lifting of up to 10 lbs. may be necessary to transport items from one care unit to the next.SUPERVISORY RESPONSIBILITY:None