Utilization Review/Case Manager (Nurse/Social Worker)

Position purpose: Utilizing approved criteria, member eligibility, and benefit coverage and/or policies, performs initial utilization reviews, including pre-admission certifications, prior authorizations, continued stay reviews, concurrent reviews, discharge reviews and retrospective reviews to verify appropriate member use of benefits at the medically necessary level of care for the member’s severity of illness and intensity of service needs.  The reviews may include but are not limited to:

As a case manager, utilizing approved PHP policies and process guidelines to conduct case management as appropriate and within the scope of their professional licensure/certification, coordinating extensive health care services in collaboration with participating providers and the members available benefits. Case Managers are responsible for the full cycle of care management for the health plan membership including proactive identification, assessment, planning, implementation, coordination, monitoring and evaluation. Case Management will be done mainly via telephone. Case Management may include but is not limited to assessing the following patients/cases:

• In-patient/Out-patient                   External resource utilization 
• Procedures                                    Level of Care Assessments
• Behavioral Health                         Chronic or complex conditions
• Medication complexity                 Home Care
• Hospice                                         Discharge Planning

Primary Responsibilities:

1. Performs utilization review and coordination of care functions.  Reviews conducted are based on approved criteria, eligibility, and benefit coverage and/or clinical policy for all levels of care, equipment and services to determine appropriateness and, when applicable, length of stay.  Identifies the most cost-effective setting, while providing quality alternatives. 
2. Reviews selective outpatient services against approved medical criteria, member eligibility, and benefit coverage and/or policy.
3. Documents the case review decisions in PHP's information system including referrals to the Medical Director, reason for recommended denial, appropriate notifications and any other information relevant to the case.
4. Participates actively in staff meetings, being prepared to discuss cases and collaborate with the multidisciplinary team on case decisions.
5. When needed, completes reviews for off-plan and out-of-network utilization and coordination of care activities.
6. Reviews relevant member medical diagnostic and treatment information compared to eligibility and benefit coverage.  Accurately enters updated member’s diagnostic and treatment information, generating individual electronic or paper documents for each treatment/service request within established timeframes.
7. Inputs patient admission and discharge information per PHP’s system, taking telephonic and electronic record reviews and assessments as needed.  Documents pertinent information sufficient to justify decision-making pertaining to the case, as well as determining the status and needs of member.
8. Refers issues or opportunities that cannot be addressed by the member’s benefit plan to the Manager of Utilization & Case Management for discussion with the management team to determine if “extra contractual” arrangements can/should be made to assist in a more cost-effective and quality alternative for the identified needs.
9. Documents and meets all reviews and notifications within the time requirements as set by federal or state code and/or PHP policy.
10. Collects and maintains accurate statistical and tracking data as required or requested by Senior Team, the Manager of Utilization & Case Management and/or department/PHP policy and process guidelines.
11. Assists in identifying community resources that will provide the member with additional support or assistance, which may not be available from the Plan’s network of health care providers.
12. Actively participates in the Quality Improvement/Utilization Review Program as well as company-wide and departmental quality management activities.  Provides assistance in the maintenance of statistics and activity documentation related to the program.  Complies with the implementation of Action Plans and process changes as a result of program activities.  Reports variations or ideas for improvement to contribute to the continuous improvement of services to members and processes of PHP. 
13. May be assigned as department representative on committees or action groups.
14. Informs the Manager of Utilization & Case Management of problematic cases, and brings forth issues that the manager needs to be aware of, serving as a constructive participant in developing responses to problems and issues.
15. Supports other Utilization Review/Case Manager/Social Worker personnel by covering their responsibilities during vacations and illness, as requested and permitted by scope of practice.
16. Leverage nursing skills to assess the needs of the member who has been identified as requiring long-term intervention by a Case Manager or who has been identified as having chronic or complex conditions. This may include completing an assessment form with the member and/or their significant other, acting within HIPAA guidelines.

1. Develops and implements a case management plan to address the member's individual needs as identified in the assessment process in collaboration with the member, the physician, the caregiver or other appropriate healthcare professional.
2. On a daily basis, makes calls to members, follows up with providers, completes general health assessments, builds case plans that reflect the needs of the member, and completes documentation, discharge planning and more.  Case Managers maintain an active revolving caseload of approximately 50 to 70 cases of varying acuity levels.
3. Coordinates health services within the scope of available benefits or refers to appropriate community resources for services that are not covered.  
4. Develops monthly or ad hoc reports on case activity and outcomes.
5. Must be proactive in identifying opportunities for cost containment.
6. Establishes and maintains a professional rapport with providers, members and internal customers, handling difficult individuals and situations with diplomacy and professionalism.
7. Demonstrates dependability and reliability.
8. Ability to work in a fast-paced environment where the individual will be expected to multitask within and outside of multiple computer systems, documenting phone conversations in the electronic record as they occur.
9. Collaborates with the provider to collect pertinent clinical documentation regarding medical, psychological and social assessments to assist in decision and alternative care options for chronic and catastrophic cases, facilitating that the member receives the right care, at the right time, and at the right location.
10. When needed, performs coordination of care functions.
11. Identifies and lists the long-term “problems or opportunities” that have been assessed on potential members requiring case management.  This process may include coordinating a case conference with other staff Case Managers, the staff Pharmacist, Plan Medical Director, member’s healthcare providers, and the member and/or the member’s significant other with the member’s consent.
12. Develops Plans-of-Care that address the significant areas of chronic and catastrophic need for the member in Case Management, utilizing various communication skills to address all the areas of implementing the Plan-of-Care.
13. Monitors the Plan-of-Care on an ongoing basis to ensure the plan has achieved a positive outcome for the member, provider, and the Plan.  As Case Manager, refines and evaluates necessary changes to the plan-of-action when reassessment of the member occurs.
14. Monitors cases and evaluates when a member no longer requires the intervention of a Case Manager or when the employer group terminates their coverage with the Plan.  In the latter event, when requested and with the patient’s authorization, provides communication with new insurer’s Case Manager/Social Worker to aid in a smooth transition of services.  In either event, a final report is documented in the member’s file.
15. Performs any relevant and related duties as required.

Experience:  Bachelor’s Degree in Nursing or a two to three (2-3) year professional Nursing/Social Work Degree.  Three (3) years of professional nursing experience, including hospital clinical-related experience preferred.  A background in utilization review, discharge planning or case management in a managed care or health care environment.  Current licensure as a Registered Nurse or Social Worker in the State of Indiana is required.  Case management certification preferred.

Critical Required Skills:

1. Must be detail-oriented, as this position will be collecting and assessing data for “plan-of-care” recommendations/implementation.
2. Must be able to accurately document pertinent case information to justify determinations, actions and recommendations.
3. Ability to self-manage, prioritize, and meet specific deadlines.
4. Highly developed communication skills.
5. Strong computer skills with the ability to operate within multiple programs simultaneously.
6. Good critical-thinking skills.
7. Ability to handle large projects and multiple tasks concurrently, within a sometimes stressful and demanding business environment.
8. Extensive knowledge of benefits, contracts and products.
9. Effective, in-depth researching skills.
10. Knowledge of database and work processing programs preferred.
11. Must be able to work well independently and in a team atmosphere.
12. Effective problem-solving skills.
13. Effective analytical abilities to collect, compile, analyze, and interpret medical information.
14. Strong negotiation skills.