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Pediatric RN for Utilization Review
2 months ago
The Role of Utilization Management RN involves overseeing the inpatient Utilization Management process, which includes both in-network and out-of-network services, case management, and discharge planning. This position also supports the Associate Director of Inpatient Management with necessary UM/QM functions and acts as a liaison to enhance collaboration between the IPA and healthcare facilities. This is an office-based role that may require some travel within the region.
Key Responsibilities:
- Conduct concurrent reviews to ensure appropriate care levels.
- Accurately document and identify levels of care.
- Coordinate and document comprehensive discharge planning.
- Facilitate in-network services for out-of-network discharges.
- Ensure proper utilization of specialists, providers, and facilities based on regional needs.
- Participate in daily inpatient review rounds, presenting cases to medical directors and case managers.
- Assist with out-of-network transfers to in-network facilities.
- Collaborate with internal staff and hospital contract personnel to:
- Initiate agreements for out-of-network services promptly.
- Provide insights for potential contracts.
- Identify and communicate high-risk cases.
- Monitor the utilization of contracted facilities.
- Build and maintain relationships with both network and out-of-network hospital staff.
- Work closely with hospitalists to enhance inpatient processes, including:
- Identifying patients for specialty clinics.
- Ensuring timely communication between primary care providers and hospitalists.
- Providing direct case management as needed.
- Identifying patients for case management coordination.
- Engage in various meetings and projects related to inpatient UM/QM.
