Job Summary:
The Nurse Case Manager/Utilization Reviewer is responsible for hospital case management/utilization review, while ensuring compliance with local, state, and federal regulatory agencies and the Centers of Medicare Services. The Nurse Case Manager/Utilization Reviewer will report to the Director of Inpatient Services and work closely with the Nurse Navigator to coordinate discharge planning and assure that patients progress through the continuum of care.
Reports to: Director, Inpatient Services
Hourly Rate: $34.00 - $54.00 / hour (hourly rate excludes overtime and bonuses which are not guaranteed.)
Essential Job Functions:
Utilization Review:
· Conduct medical record reviews using specific indicators and criteria as approved by medical staff, CMS, and other state and federal agencies while ensuring physician and nurse documentation meets set standards.
· Demonstrate compliance with the insurance criteria and, as a result, facilitate the appropriate admission status based on documentation of medical necessity.
· Provide Prospective Review pre-operatively to identify the appropriate level of care.
· Review medical records concurrently for appropriateness of level of care and discharge planning.
· Provide utilization review for preauthorization, as well as concurrent, discharge, and post-service reviews using the hospital-approved criteria software.
· Provide admission and discharge notifications to insurance companies as required.
· Transmit Continuity of Care Documents to appropriate providers for follow-up.
· Collaborate with physicians to ensure correct orders and documentation to support medical necessity.
· Collaborate with physicians if the case does not meet admission or continued stay criteria.
· Complete admission status changes into the hospital computer system, including registration, insurance verification, and authorizations.
· Investigate and report adverse occurrences and perform staff education related to resource utilization.
· Prevents denials and disputes by communicating with payers and documenting relevant information.
· Advocates for the patient and hospital with payers to secure appropriate payment for services rendered.
· Identifies and documents Avoidable Days using the data to address opportunities for improvement.
· Promotes appropriate length of stay guidelines.
· Must participate in the Discharge Planning Committee.
· May be required to run and/or participate in the Utilization Review Committee Meeting.
· Assist the Quality Director with data gathering as needed to support regulatory reporting.
· Work collaboratively with the Nurse Navigator to meet the needs of patients and caregivers.
· Communicate effectively, professionally, accurately, and timely with all staff and patients.
· Perform other duties as assigned or required.
Case Management
· Screen for medical necessity for the status of patients who are admitted as inpatients, placed in observation and/or outpatient services or outpatient in a bed utilizing pre-approved medical necessity guidelines.
· Understand case management rules and guidelines to ensure compliance.
· The Case Manager educates members of the healthcare team on case management and managed care concepts. Serves as the patient advocate and enhances a collaborative relationship with the healthcare team, physicians, patients, and families to maximize the patient’s and family’s ability to make informed healthcare decisions.
· This position reinforces and facilitates patient/family education to enhance a positive discharge transition.
· Responsible for ensuring discharge goals are being met, and identifying barriers to discharge, including but not limited to, having proper DME, home health services, home medication management, home oxygen, and physical therapy in place before discharge.
· Place referrals for follow-up services as ordered by providers.
· Investigate and report adverse occurrences, and perform staff education related to resource utilization, discharge planning, and psychosocial aspects of healthcare delivery.
· The RN Case Manager will assist the Quality Director with data gathering as needed to support regulatory reporting.
· The Case Manager is responsible for collecting and maintaining the monthly Case Management Metric Dashboard.
· Trend barriers in discharge delays or concerns.
· Lead the inpatient team through quality improvement projects by utilizing identified areas of improvement through patient satisfaction surveys.
· Works collaboratively with nursing staff and the Nurse Navigator to support meeting the psycho-social needs of patients and families or caregivers.
· Perform other duties as assigned or required.
Additional Responsibilities:
· Assist the Inpatient Director and PCU Supervisors with inpatient chart audits, medication audits, antibiotic audits, and unit-specific tracking tools.
· Must demonstrate high attention to detail, the ability to multitask, prioritization, and strong problem-solving skills to address issues that arise unexpectedly.
· Must encompass the skill to follow through with tasks and situations while providing clear communication to others throughout the process.
· Model professional behavior in accordance with the ASH code of conduct
· Support and facilitate initiatives enhancing patient satisfaction.
· Communicate effectively, professionally, accurately, and timely manner with all staff and patients.
· Demonstrates the spirit of the philosophy, mission, and values of the hospital through words and actions and implements them into departmental processes, programs, and the working environment.
Minimum Requirements:
Education: Graduation from an accredited school of nursing. Bachelor of Science in Nursing preferred.
Certification, Licensure: Current State license as a registered nurse; current CPR certification; BLS, ACLS, PALS or TNCC certifications per policy. Case Management Certification(s) preferred.
Training: Must complete hospital-provided Milliman Care Guidelines (MCG) training within 30 days of hire.
Experience, Training, Knowledge: Previous experience with Case Management, Discharge Planning, and Utilization Review preferred. Previous experience with InterQual System or Milliman Care Guidelines (MCG) preferred.
Physical Requirements:
Requires reaching, grasping, handling, and/or feeling five (5) or more hours per day in order to record data, operate computer/word processing equipment, etc.; visual acuity to maintain various records/reports, prepare forms, utilize automated processes, comprehension of written instructions, etc.; audio acuity to respond to requests, instruction and questions.
Working Conditions/Environmental Exposures: Exposure to environmental hazards such as chemicals, solvents, needles, needle containers, sharps, blood, body fluids, various infections/communicable diseases, infectious medical waste, radiation and/or radioactive materials and/or radioactive waste, proximity to moving mechanical parts. Protective clothing/equipment may be necessary.
ASH IMMUNIZATIONS AND VACCINATIONS REQUIREMENTS – Aligns with CDC’s Advisory Committee on Immunization Practices (ACIP) for Healthcare Personnel
Hepatitis B- Lab evidence of immunity (titer) to Hepatitis B or three doses Hep B vaccine at appropriate intervals
Influenza- documentation of current seasonal flu vaccine (mandatory from November 1st through March 31st each year)
Measles, Mumps, and Rubella - Lab evidence of immunity (titer) to Measles, Mumps, and Rubella or 2 doses of MMR Vaccination
Varicella (chickenpox) - Lab evidence of immunity (titer) to Varicella or 2 doses of Varicella Vaccine
Tetanus, diphtheria, pertussis (Tdap) - documented proof of immunization
Tuberculosis Screening - Documentation of a two-step TB skin test within the past year OR lab verification of a negative TB Gold or T-Spot tuberculin test within the past 6 months
* VACCINE RECORDS OR EVIDENCE OF IMMUNITY ARE REQUIRED PRIOR TO 1ST DAY OF SCHEDULED WORK