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Utilization Review Case Manager

Torrance Memorial Medical Center
Full-time
On-site
Torrance, California, United States
$52.88 - $80.45 USD hourly
Healthcare Insurance and Claims

Description

Under general supervision, the Utilization Review Case Manager (UR CM) performs review of patient charts as defined by the Hospital's Utilization Review Plan. The UR CM validates the patient’s admission status and level of care to be at the most appropriate based on nationally accepted admission criteria. The UR CM uses medical necessity screening tools, such as MCG criteria to complete initial and continued stay reviews in determining appropriate admission and continued stay status and level of patient care. The UR CM secures authorization for the patient’s clinical services through collaboration and communication with payers as required. The UR CM follows the UR process as defined in the Utilization Review Plan in accordance with the CMS condition of Participation for Utilization Review.

Core Competencies

  • Adheres to policies, procedures, and standards of practice to deliver safe and optimal care

  • Complies with Joint Commission’s national patient safety goals

  • Complies with organizational quality dashboard/benchmarking goals

  • Maintains regulatory compliance consistent with quality standards and ethical obligations of the profession

  • Participates in activities in alignment with the Magnet Model

  • Participates in organizational committees, task forces and/or projects including presentation of project reports, committee recommendations, and task force activities at the unit level.

  • Participates in Peer Review

  • Participates in professional development activities

  • Provides patient and family education throughout the care of patient

  • Performs as a preceptor in an active and engaged manner

  • Provides age specific and culturally competent discharge planning to all patients.



Department Specific Competencies

  • Attends denial management committee.

  • Identifies and monitors Observation cases on a daily basis.

  • Performs retrospective reviews.

  • Reviews all commercial accounts daily or as per contract or payer expectation

  • Collaborates with RN Case Managers and the Physician Advisors to facilitate the peer to peer process in order to mitigate potential denials

  • Demonstrates independent judgment, autonomy, initiative, time management and organizational skills and the ability to prioritize projects/functions in a busy work environment.



Education

DegreeProgram
BachelorsNursing

Additional Information

Experience

Number of Years ExperienceType of Experience
1Acute hospital case management, Health Plan Utilization Review
2Clinical experience in an acute care facility

Additional Information
N/A

License / Certification Requirements

Registered Nurse License
Compensation Range
$52.88 - $80.45 / Hour

 

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