Transfer and Admissions Utilization Manager

2 days ago

San Diego, California, United States Sharp HealthCare Full time

Job Summary:

The Transfer and Admissions Utilization Manager plays a critical role in the System Integrated Care Management team, partnering with the Centralized Patient Placement Center (CPPC) RNs to review external and internal transfer requests and direct admission requests. This position supports utilization review functions to ensure appropriate patient status and assists with repatriation and post-stabilization reviews for patients before the patient is bedded, during the episode of care, and supports other members of the System Centralized Utilization Management team to ensure final status reconciliation.

Key Responsibilities:

  • Partners with CPPC and Revenue Cycle team to act as a consult for external and internal transfer and direct admission requests to ensure medical necessity and payer considerations are reviewed.
  • Performs initial and concurrent review on intent to bed or bedded patients, working collaboratively with system emergency departments (ED), attending physicians, and the physician advisor.
  • Assists in the repatriation and post-stabilization process to mitigate denials, engaging and conferring with the physician advisor as needed.
  • Identifies and escalates cases not meeting criteria for admission or concurrent stay, working proactively to identify solutions and advising the physician advisor of these cases to mitigate denials.
  • Reviews hospitalized patients with the Physician Advisor and/or facility UR chairperson as requested or required by plan/group/payer.
  • Identifies and reports upon emerging variances or trends counter to the division and organizational objectives.
  • Maintains records and statistics as required, including bed days, discharges, re-admissions, and diagnoses.
  • Ensures accurate and timely completion of all documentation requirements.
  • Coordinates transfer of 'out-of-network' patients when indicated, maintaining confidentiality of all patient and Utilization Management information.
  • Participates in ICM Care Conferences as requested, working collaboratively with other members of the healthcare team and medical groups to facilitate the utilization management process.
  • Identifies and refers situations needing immediate intervention to UR Manager, Physician Advisor, as appropriate.

Requirements:

  • Bachelor's Degree in a health-related field.
  • 3 years of Utilization Management or case management experience within a hospital or payer setting.
  • 3 years of acute care nursing experience.
  • 2 years of recent pertinent clinical experience as defined by the CBA.
  • California Registered Nurse (RN) - CA Board of Registered Nursing -REQUIRED.
  • Preferred qualifications include Associate's Degree in Nursing, experience with Milliman Care Guidelines (MCG), and understanding of federal and state regulations governing utilization management.

About Sharp HealthCare:

Sharp HealthCare is an equal opportunity/affirmative action employer, committed to providing a work environment free from discrimination and harassment. We strive to attract and retain top talent from diverse backgrounds and perspectives, fostering a culture of inclusivity, respect, and collaboration.

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