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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 healthcare environment, collaborating with multidisciplinary teams to review medical necessity and appropriateness of care. You will work closely with physicians, nurses, and other healthcare professionals to ensure that patients receive the right care, at the right time, and in the right setting.
Responsibilities:- Perform admission and concurrent reviews to identify medical necessity, level of care, and appropriateness of setting using established criteria and clinical guidelines.
- 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 and work 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 and participate in 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 and pursue 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, intervene 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 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.).
Shaker for ChristianaCare Direct offers:
- Medical, dental, vision, life insurance, tuition assistance, etc.
- Two retirement planning offerings, including 403(b) with company contributions.
- Generous paid time off with annual rollover and opportunities to cash out.
- 12-week paid parental leave.
- Incredible work/life benefits, including annual membership to, access to backup care services for dependents through, retirement planning services, financial coaching, fitness and wellness reimbursement, and great discounts through several vendors for hotels, rental cars, theme parks, shows, sporting events, movie tickets, and much more.
