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Clinical Utilization Specialist
2 months ago
Shaker for ChristianaCare Direct is seeking a skilled Clinical Utilization Specialist 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.
Job Summary:We are looking for a highly motivated and detail-oriented individual to work collaboratively with our healthcare team to review medical necessity and appropriateness of healthcare services. The ideal candidate will have a strong background in clinical documentation, performance improvement, and case management.
Responsibilities:- Perform admission and concurrent review to identify medical necessity, level of care, and appropriateness of setting using established criteria and clinical guidelines within 24 hours of admission.
- Review admission assessments, 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 caring for patients to ensure observation status does not exceed 48 hours.
- Identify system issues that serve as barriers to care, 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 unit medical directors and/or physician advisors to facilitate achievement of clinical, quality, financial, and patient satisfaction goals.
- Notify physicians when patients do not meet criteria for acute care hospitalization, pursue documentation to justify continued stay within 24 hours.
- Collaborate with physician advisors to facilitate achievement of clinical, quality, financial, and patient satisfaction goals.
- Present "Letters of Non-Coverage" to patients and/or families when acute stays are 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.
- Provide on-call support for the Transfer Center to evaluate medical necessity and appropriateness when requests are obtained from outside facilities for patient transfers to Christiana Care.
- Identify needs for patients to be evaluated by other members of the healthcare team and take appropriate action to facilitate.
- 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.
- Ability to ambulate within the hospital setting (walking, stairs, etc.).
- Ability to utilize computer equipment/programs.
- Ability to sit or stand at a computer workstation and proficiently utilize computer equipment/programs for long periods of time.
Christiana Care is one of the country's most dynamic healthcare organizations, centered on improving health outcomes, making high-quality care more accessible, and lowering healthcare costs. Christiana Care includes an extensive network of outpatient services, home health care, urgent care centers, three hospitals (1,336 beds), a free-standing emergency department, a Level I trauma center, a Level III neonatal intensive care unit, a comprehensive stroke center, and regional centers of excellence in heart and vascular care, cancer care, and women's health.
Christiana Care offers a comprehensive benefits package, including medical, dental, vision, life insurance, tuition assistance, and retirement planning. We also offer generous paid time off, 12-week paid parental leave, and 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.
