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Utilization Review Registered Nurse
2 months ago
Position Overview:
The Care Manager is accountable for ensuring the documentation of medical necessity for inpatient admissions or observation placements is accurate and timely. This role involves effective communication with physicians and clinical staff to facilitate the authorization process with payors.
Key Responsibilities:
- Employs a comprehensive approach to assess, plan, implement, and evaluate patient care coordination from pre-admission through post-discharge.
- Contributes to the creation of physician profiles to identify patterns of over and under-utilization.
- Aligns with organizational goals and adheres to regulatory compliance standards.
- Collaborates with various healthcare professionals to ensure timely and appropriate service delivery.
- Evaluates the medical appropriateness, quality, and cost-effectiveness of proposed healthcare services.
- Works with a multidisciplinary team to assist patients with managing their benefits.
- Engages with payers to secure necessary authorizations.
- Identifies strategies to optimize inpatient length of stay and resource utilization.
Required Skills and Knowledge:
- Proficient in computer-based documentation and various clinical software applications.
- Demonstrates adaptability and possesses strong organizational skills. Must be able to communicate effectively in English.
- Expected to deliver presentations as needed. Familiarity with Medicare, Medicaid, HMO, and private insurance coverage criteria is essential.
- Ability to advocate for patients and operate standard office equipment. Critical thinking skills are necessary.
- Leadership capabilities are essential, including mentoring, coaching, time management, problem-solving, and strategic planning.
- Proactive in resolving issues and demonstrating initiative.
- Ability to interact effectively with insurance providers and community healthcare resources.
- Capable of thriving in a fast-paced and stressful environment.
- Proficient in Microsoft Office Suite, including Excel and Word.
- Knowledge of CMI, patient status, InterQual Criteria, Milliman Criteria, and Transfer DRGs is required.
- Must possess the maturity to work independently and remotely.
Education and Experience:
- Education: Bachelor's degree required; Master's degree preferred.
- Experience: A minimum of three to five years in acute medical/surgical settings, alongside three to five years in Case Management.
- Licensure: Active RN license required; Certification in Case Management (CCM) is strongly preferred.
- Technical Skills: Strong proficiency in Microsoft Office applications - Word, Excel, Access, PowerPoint.
- Other: A solid understanding of the healthcare delivery system is essential.
