UNC REX Healthcare
Description
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Summary The Utilization Manager (UM) assesses new admissions, continued stay and discharge review cases for medical necessity, appropriate class and level of care (LOC). This position works collaboratively with an interdisciplinary team (including physicians, other care providers, payers, etc.) to ensure the patient’s needs are met and care delivery is coordinated. The UM completes utilization reviews in accordance with federal regulations and the health system’s Utilization Review Plan.
Responsibilities
Use approved criteria and conduct admission review/class change review as triggered by patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identify and obtain observation services as appropriate. Partner with physicians, nursing, and other care providers to ensure timely and accurate documentation of patient data and treatments. Communicate daily with the Care Manager to manage level of care transitions and appropriate utilization of services. Coordinate with appropriate staff/payers to assure third‑party payer pre‑certification and/or re‑certifications when required. Discharge facilitation: utilize high‑risk screening criteria to make appropriate referrals. Identify patient/families with complex psychosocial, ongoing medical transition planning issues and continuing care needs by initiating appropriate care management referrals and social work referrals.
Perform utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients to ensure optimal patient outcomes. Using approved criteria, conduct initial and continued stay reviews to monitor the patient’s progress along the continuum of care and intervene as necessary to ensure appropriateness of setting and that the services provided are quality‑driven, efficient, and effective. Enter all pertinent review data into the correct computer system in a timely manner. Consult with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels.
Monitor and guide interdisciplinary documentation to improve coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitate patient movement to appropriate acuity level of care, including observation services issues through collaboration with patient representative, multidisciplinary team, third‑party payers and care managers/social workers. Provide information regarding denials and approvals to appropriate staff and/or designated entities. Document and deliver notifications to patients, patient representative, and/or appropriate staff. Review pre‑scheduled surgery admissions for proper status order for inpatient‑only procedures.
Collaborate to problem‑solve issues with complex patients and identify trends. Formulate potential solutions with Care Manager and Social Worker and continuously monitor cases/follow up on all action items. Proactively identify high‑risk cases that need to be escalated to the list that are not scheduled for discussion that week.
Qualifications
Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states.
Two (2) years of experience working as a Registered Nurse.
Strong verbal and written communication.
Basic Life Support (BLS) certification.
Preferred: Bachelor’s of Science in Nursing (BSN).
Preferred: Certification in Case Management.
PARDEE
01.6015.1542
Job Details Legal Employer: Pardee - HCHC
Entity: Pardee UNC Health Care
Organization Unit: Acute Care Case Management
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: PARDEEHOSP
Exempt From Overtime: Exempt: No
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.
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Summary The Utilization Manager (UM) assesses new admissions, continued stay and discharge review cases for medical necessity, appropriate class and level of care (LOC). This position works collaboratively with an interdisciplinary team (including physicians, other care providers, payers, etc.) to ensure the patient’s needs are met and care delivery is coordinated. The UM completes utilization reviews in accordance with federal regulations and the health system’s Utilization Review Plan.
Responsibilities
Use approved criteria and conduct admission review/class change review as triggered by patient admission to the hospital to ensure appropriateness of the setting and timely implementation of the plan of care. Identify and obtain observation services as appropriate. Partner with physicians, nursing, and other care providers to ensure timely and accurate documentation of patient data and treatments. Communicate daily with the Care Manager to manage level of care transitions and appropriate utilization of services. Coordinate with appropriate staff/payers to assure third‑party payer pre‑certification and/or re‑certifications when required. Discharge facilitation: utilize high‑risk screening criteria to make appropriate referrals. Identify patient/families with complex psychosocial, ongoing medical transition planning issues and continuing care needs by initiating appropriate care management referrals and social work referrals.
Perform utilization management assessments and interventions, using collaboration with interdisciplinary team approach, on assigned patients to ensure optimal patient outcomes. Using approved criteria, conduct initial and continued stay reviews to monitor the patient’s progress along the continuum of care and intervene as necessary to ensure appropriateness of setting and that the services provided are quality‑driven, efficient, and effective. Enter all pertinent review data into the correct computer system in a timely manner. Consult with Physician Advisor as necessary to resolve barriers through appropriate administrative and medical channels.
Monitor and guide interdisciplinary documentation to improve coding accuracy, enhance quality of care, reflect accurate severity of illness and appropriate reimbursement. Facilitate patient movement to appropriate acuity level of care, including observation services issues through collaboration with patient representative, multidisciplinary team, third‑party payers and care managers/social workers. Provide information regarding denials and approvals to appropriate staff and/or designated entities. Document and deliver notifications to patients, patient representative, and/or appropriate staff. Review pre‑scheduled surgery admissions for proper status order for inpatient‑only procedures.
Collaborate to problem‑solve issues with complex patients and identify trends. Formulate potential solutions with Care Manager and Social Worker and continuously monitor cases/follow up on all action items. Proactively identify high‑risk cases that need to be escalated to the list that are not scheduled for discussion that week.
Qualifications
Must be licensed to practice as a Registered Nurse in the state of North Carolina or one of compact states.
Two (2) years of experience working as a Registered Nurse.
Strong verbal and written communication.
Basic Life Support (BLS) certification.
Preferred: Bachelor’s of Science in Nursing (BSN).
Preferred: Certification in Case Management.
PARDEE
01.6015.1542
Job Details Legal Employer: Pardee - HCHC
Entity: Pardee UNC Health Care
Organization Unit: Acute Care Case Management
Work Type: Full Time
Standard Hours Per Week: 40.00
Work Assignment Type: Onsite
Work Schedule: Day Job
Location of Job: PARDEEHOSP
Exempt From Overtime: Exempt: No
Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.
#J-18808-Ljbffr