Utilization Management Specialist

Position Summary:

Responsible for the coordination and implementation of case management strategies pursuant to the Case Management process. Plans and coordinates care of the patient from pre-hospitalization through discharge. Responsible for authorization of appropriate services for continued stay and through discharge. Conducts reviews with insurance companies to ensure coverage for patient admissions. Participates in performance improvement activities. Attends 80% of staff meetings. Coordinates care for patient through communication with Physicians, Nurse Practitioners, Clinical Services, Nursing, Assessment and Referrals Department. Attends treatment team meetings as scheduled.

Position Responsibilities:

Clinical / Technical Skills (40% of performance review)

• Reviews intake assessment on patient within 24 hours of admission (patients meeting screening criteria).
• Develops, implements and evaluates individualized patient care plans to meet the needs of patients.
• Reviews care and treatment for appropriateness against screening criteria and for infection prevention and control, quality and risk assessment; documenting same in computerized database.
• Performs follow-up assessments per Case Management Plan and/or department policy.
• Utilizes clinical pathways whenever ordered by physician, to facilitate coordination of patient care.
• Evaluates patient care plans on a regular basis and updates the care plans when needed.
• Plans patient care in collaboration with all members of the healthcare team.
• Consults with other departments, as appropriate, to collaborate in patient care and performance improvement activities. Collaborates with other departments to identify operational problems and develop solutions/resolution.
• Works with all members of the healthcare team to assure a collaborative approach is maintained in care and treatment of the patient.
• Works closely with social worker to integrate psychosocial management of patient/family needs.
• Works with third party payers to validate need for patient care and home care environment needs.
• Reviews patient care activities for occurrences and trends that affect the quality, cost effectiveness and delivery of services. Assures that the outcome of review is appropriately maintained in the computer database.
• Assumes responsibility for timely completion of required case management reports for hospital leadership, regulatory bodies, health plans, insurance carriers, etc.
• Possesses knowledge of Medicare, Medicaid and private insurance providers.
• Assists the Utilization Management Department with all utilization activities as requested and directed.
• Participates in education on and implementation of clinical guidelines and protocols.
• Documentation meets current standards and policies.
• Functions as a patient/family advocate ensuring each patient receives the most cost-effective care possible.
• Maintains optimal continuum of patient care through efficient and effective planning, assessing and coordination of healthcare services.
• Demonstrates an ability to be flexible, organized and function under stressful situations.
• Maintains a good working relationship both within the department and with other departments.
• Remains current on case management theory and practice, psychosocial issues current within the community and the healthcare environment.

Safety (15% of performance review)

• Strives to create a safe, healing environment for patients and family members
• Follows all safety rules while on the job.
• Reports near misses, as well as errors and accidents promptly.
• Corrects minor safety hazards.
• Communicates with peers and management regarding any hazards identified in the workplace.
• Attends all required safety programs and understands responsibilities related to general, department, and job specific safety.
• Participates in quality projects, as assigned, and supports quality initiatives.
• Supports and maintains a culture of safety and quality.

Teamwork (15% of performance review)

• Works well with others in a spirit of teamwork and cooperation.
• Responds willingly to colleagues and serves as an active part of the hospital team.
• Builds collaborative relationships with patients, families, staff, and physicians.
• The ability to retrieve, communicate, and present data and information both verbally and in writing as required
• Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word.
• Demonstrates adequate skills in all forms of communication.
• Adheres to the Standards of Behavior

Integrity (15% of performance review)

• Strives to always do the right thing for the patient, coworkers, and the hospital
• Adheres to established standards, policies, procedures, protocols, and laws.
• Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence.
• Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
• Completes required trainings within defined time periods.
• Exemplifies professionalism through good attendance and positive attitude, at all times.
• Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws.
• Ensures proper documentation in all position activities, following federal and state guidelines.

Compassion (15% of performance review)

• Demonstrates accountability for ensuring the highest quality patient care for patients.
• Willingness to be accepting of those in need, and to extend a helping hand
• Desire to go above and beyond for others
• Understanding and accepting of cultural diversity and differences

Education

• Required: Current unencumbered RN in the state of employment, or Masters degree in healthcare administration or behavioral health, with an unencumbered license as LPC, LMFT, LSW, LISW, LISW-S, LPCC, LPCC-S, LMSW, or LCSW, or state equivalent license.  CPR and hospital-selected de-escalation technique certification.
• Maintains education and development appropriate for position.

Experience

• Required: One or more years case management experience.
• Preferred: One or more years acute hospital, home health, hospice, inpatient mental facility experience required (as applicable).
• May substitute education for required experience.