Utilization Review Case Manager

Under general supervision, the Utilization Review Case Manager (UR CM) performs review of patient charts as defined by the Hospital's Utilization Review Plan. The UR CM validates the patient’s admission status and level of care to be at the most appropriate based on nationally accepted admission criteria. The UR CM uses medical necessity screening tools, such as MCG criteria to complete initial and continued stay reviews in determining appropriate admission and continued stay status and level of patient care. The UR CM secures authorization for the patient’s clinical services through collaboration and communication with payers as required. The UR CM follows the UR process as defined in the Utilization Review Plan in accordance with the CMS condition of Participation for Utilization Review.

Core Competencies

Adheres to policies, procedures, and standards of practice to deliver safe and optimal care

Complies with Joint Commission’s national patient safety goals

Complies with organizational quality dashboard/benchmarking goals

Maintains regulatory compliance consistent with quality standards and ethical obligations of the profession

Participates in activities in alignment with the Magnet Model

Participates in organizational committees, task forces and/or projects including presentation of project reports, committee recommendations, and task force activities at the unit level.

Participates in Peer Review

Participates in professional development activities

Provides patient and family education throughout the care of patient

Performs as a preceptor in an active and engaged manner

Provides age specific and culturally competent discharge planning to all patients.

Department Specific Competencies

Attends denial management committee.

Identifies and monitors Observation cases on a daily basis.

Performs retrospective reviews.

Reviews all commercial accounts daily or as per contract or payer expectation

Collaborates with RN Case Managers and the Physician Advisors to facilitate the peer to peer process in order to mitigate potential denials

Demonstrates independent judgment, autonomy, initiative, time management and organizational skills and the ability to prioritize projects/functions in a busy work environment.

Education

Degree:

Bachelors

Program:

Nursing

Experience

Number of Years Experience:

1

Type of Experience:

Acute hospital case management, Health Plan Utilization Review

2

Type of Experience:

Clinical experience in an acute care facility

License / Certification Requirements Registered Nurse License

Compensation Range:

$52.88 - $80.45 / Hour

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