Under the general supervision of the UM Team Manager, this individual performs UM activities which includes admission review, concurrent review, retrospective chart review and clinical systems review to measure clinical performance and UM issues that affect reimbursement for the patient's hospital stay or visit. Responsibilities include medical record review, providing clinical information to the payer, UM data collection and reporting, concurrent denials appeals process, clinical team interaction, Physician Adviser interaction and special projects which are coordinated and directed by the UM Team Manager. May design and initiate special projects as supervised by the Team Manager.
- Recommends resource utilization.
- Prioritizes and organizes work to meet changing priorities.
- Utilizes analytical ability required to gather data. Uses clinical judgment to apply predetermined criteria or uses independent clinical judgment when no predetermined criteria exists to identify problems, facilitate resolution, recommend corrective action, and report results effectively.
- Uses independent clinical judgment in reviewing records to determine status of patients stay, if proper procedures have been followed, seriousness of incidents and ability to identify need for and participate in focused reviews, special projects and identify opportunities for improvement.
- Makes recommendations regarding appropriateness of the treatment plan for continued stay and safety of the discharge plan.
- Achieves a minimum of 85% on IRR quarterly.
- Completes Utilization Management for assigned patients with a minimum of 25-30 reviews per day.
- Applies medical necessity guidelines accurately to monitor appropriateness of admission and continued stays.
- Follows department guidelines on escalation processes and refer cases appropriately to the internal or external PA.
- Maintains professional work standards including confidentiality, ethical principles, and professional work habits.
- Maintains and supports collaborative relationships with TCC's, Physicians and the multidisciplinary team.
- Documents appropriately in UM notes to provide evidence that the UR process for the case was followed.
- Attend all staff meeting when scheduled to work.
- Other duties as assigned.
- Work Shift 8-4:30
- Every other weekend requirement
- Graduate of an accredited school of nursing with licensure as a Registered Nurse (RN) in the State of Ohio.
- Bachelor of Science in Nursing preferred.
- Current valid license in the State of Ohio as a Registered Nurse (RN).
- Case Management Certification (CCM) preferred within first year of eligibility.
- Basic Life Support (BLS) through American Heart Association (AHA).
- Requires three years equivalent full-time clinical experience as a Registered Nurse.
- Prior Utilization Management experience is preferred.
- Knowledge of medical terminology, anatomy and physiology, diagnosis, surgical procedures, and basic disease processes.
- Analytical ability required to gather data, decide on conformity based on predetermined criteria, identify problems and refer for resolution.
- Basic knowledge of medical records coding standards.
- Awareness of licensing and accreditation standards.
- Proficient with Microsoft Office.
- Knowledge of billing practices, identification of billing problems, adequacy of documentation, and ability to conduct research of issue at hand, as well as formulate recommendations based on findings; capable of providing in-service education to health care providers in regard to this topic.
- Knowledge and experience with Care Guidelines, Medical Necessity Criteria and/or other UM criteria sets.
- Must possess advanced interpersonal and communication written and verbal skills necessary to gather and exchange data (both internally and externally) with members of the health care team.
- Ability to assess medical records and make determinations on length of stay and proper procedures in accordance with policies and procedures, with experience in assigned specialty.
- Demonstrated competence in all areas identified in the Competencies, Dimensions, Problem solving, and Information Management sections Participates in departmental cost containment; cognizant of reimbursement denials and effect on cost of care.
- Knowledge of and ability to use multiple Hospital information systems and Department's software; report and follow-up on software problems resulting in delay in work flow.
- Ability to use copier, fax machine and personal computer and knowledge of Microsoft Office.
- Requires walking, sitting, and/or standing for long periods of time.
- Requires constant attention to detail, reading of medical records, and meeting deadlines.
- Works in an environment where there is some discomfort due to dust, noise, temperature.
Personal Protective Equipment:
- Follows standard precautions using personal protective equipment.