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Clinical Utilization Manager
2 months ago
Job Description
Position Overview
Full-time exempt role, 40 hours per week focused on Medical Necessity Review for Surgical Admissions
Become part of a diverse organization dedicated to enhancing the health and well-being of the communities we serve.
Role Summary:
Collaborates with patients, families, and an interdisciplinary team, including physicians and payors, to evaluate patient care progression from acute care through post-discharge, ensuring quality, efficiency, and effectiveness. The Utilization Manager partners with Clinical Care Management staff to meet patient needs and coordinate care delivery across the continuum. Responsibilities include conducting admission, continued stay, and discharge reviews in line with federal regulations and the organization's Utilization Management Plan. The role also involves revenue protection through the reconciliation of physician orders, bed billing types, and medical necessity notifications to patients.
Key Responsibilities:
1. Clinical Review Process: Utilizes approved criteria to conduct admission and status change reviews within 24 hours of patient admission, ensuring the appropriateness of care settings and timely care plan implementation. Collaborates with physicians and nursing staff to ensure accurate patient data documentation. Maintains daily communication with Case Managers to manage care transitions and service utilization.
2. Discharge Facilitation: Identifies patients and families facing complex psychosocial and ongoing medical discharge planning needs, initiating appropriate case management and social work referrals.
3. Utilization Management Process: Performs assessments and interventions using an interdisciplinary approach to ensure optimal patient outcomes. Conducts continued stay and quality reviews to monitor patient progress and intervenes as necessary to maintain quality-driven, efficient care. Enters relevant review data into the appropriate systems promptly.
4. Utilization Outcomes Management: Monitors interdisciplinary documentation trends and guides medical staff in accurate documentation to enhance coding accuracy and quality of care. Facilitates patient movement to appropriate care levels, including observation status, through collaboration with patients, families, and third-party payors. Provides information regarding denials and approvals to relevant entities.
Additional Information:
Education Requirements:
* Graduation from a state-accredited nursing program.
* If hired after a specified date, must enroll in an accredited program within four years and obtain a Bachelor's or Master's degree in Nursing within seven years of employment.
Licensure/Certification Requirements:
* Must be licensed as a Registered Nurse in the state of North Carolina.
Professional Experience Requirements:
* Minimum of two years of clinical experience in a medical facility or comparable Utilization Management experience.
Knowledge, Skills, and Abilities:
Job Details:
Legal Employer: NCHEALTH
Entity: UNC REX Healthcare
Organization Unit: Rex Case Management Services
Work Type: Full Time
Standard Hours Per Week: 40.00
Salary Range: $49.81 per hour (Hiring Range)
Work Assignment Type: Onsite
Work Schedule: Day Job
Exempt From Overtime: Yes
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status. Reasonable accommodations are made for applicants' and employees' religious practices and beliefs, as well as for those with disabilities.
