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Clinical Utilization Manager
2 months ago
Shaker for ChristianaCare Direct is seeking a skilled Clinical Utilization Manager to join our team. As a key member of our Utilization Management team, you will play a critical role in ensuring the delivery of efficient and effective healthcare services.
About the Role:This is a unique opportunity to work in a dynamic and fast-paced environment, collaborating with a multidisciplinary team to review medical necessity and appropriateness of healthcare services. You will work closely with ED providers, nursing staff, and other healthcare professionals to ensure that patients receive the best possible care.
Responsibilities:- Perform admission and concurrent review to identify medical necessity, level of care, and appropriateness of setting using established criteria and clinical guidelines.
- Review admission assessments, collaborate with primary nurses, and other healthcare providers to ensure a multidisciplinary plan-of-care is in place to meet identified patient care needs and desired outcomes.
- Manage observation level of care, working with attending physicians and/or clinical providers to ensure observation status does not exceed 48 hours.
- Identify system issues that serve as barriers to care, participating in the development and implementation of strategies to remove barriers and facilitate performance improvement measures.
- Monitor efficiencies in scheduling diagnostic procedures and coordination of treatments to facilitate achievement of effective clinical, fiscal, quality, and patient satisfaction goals.
- Report information generated from the utilization management referral process for LOS data and physician profile database.
- Collaborate with the unit medical director and/or physician advisor to facilitate achievement of clinical, quality, financial, and patient satisfaction goals.
- Notify physicians when patients do not meet criteria for acute care hospitalization, pursuing documentation to justify continued stay within 24 hours.
- Collaborate with the Physician Advisor to facilitate achievement of clinical, quality, financial, and patient satisfaction goals.
- Present "Letters of Non-Coverage" to patients and/or families when acute stay is no longer necessary (Third Party and/or Medicare).
- Communicate and secure continued stay authorization with Managed Care Organizations.
- Track all carve-outs and submit reason codes for data entry.
- Serve as a resource to nursing and ancillary staff, providing education on utilization review processes as needed.
- Trend potential barriers to patient advancement through the system, intervening assertively and appropriately when necessary.
- Provide on-call support for the Transfer Center to evaluate medical necessity and appropriateness when a request is obtained from an outside facility for patient transfer to Christiana Care.
- Identify the need for patients to be evaluated by other members of the healthcare team and take appropriate action to facilitate.
- Active DE RN licensure or compact state RN licensure.
- Bachelor's degree in nursing.
- Minimum of 3 years recent experience as a Registered Nurse in acute care, adult care setting.
- Clinical documentation, performance improvement, case management, or utilization management experience desirable.
- Completes a minimum of 8 continuing education credits (CEU's) per year in utilization and/or case management.
- Actively participates in department operational planning work groups.
Occasional exposure to office materials (i.e., White Out, Toner, etc.).
Ability to ambulate within the hospital setting (walking, stairs, etc.). Occasional sitting, standing, and lifting loads of 5-10 pounds. Ability to utilize computer equipment/programs. Ability to sit or stand at a computer workstation and proficiently utilize computer equipment/programs for long periods of time.
Special rate of pay and full benefits, except for Paid Time Off (PTO), as part of our Weekend Incentive Program.
