Nurse Care Manager & Utilization Review

Gillette Children's•St Paul, MN

4d•Onsite

About The Position

Performs preadmission, concurrent, and retrospective reviews of by direct contact with inpatients, clinical staff, and the medical record using pre-established, objective, quality of care, coding, and medical necessity criteria to monitor patient care rendered. Provides decision support by communicating findings to nursing, social work, providers, or others. Negotiates reimbursement directly with payers or refers complex cases to manager or designee. Provides inpatient care management for identified hospitalized medical and surgical patients. Collaborates with the interdisciplinary care team to facilitate the achievement of optimal outcomes in a cost effective manner. Negotiates and coordinates services and resources needed to reach the identified goals. Continuously evaluates the effectiveness of the care management plan with the physician and rest of the healthcare team and modifies as needed. Communicates with the patient, family and healthcare team regarding progress on plan.

Requirements

Current RN license through the MN Board of Nursing
Bachelor’s degree, preferably in Nursing or other healthcare related field
Current BLS certification (Basic Life Support through the American Heart Association) or obtain within 90-days of hire.
Must be interested in working with people with short term or long term disabilities that begin in childhood
A minimum of 5 years recent clinical experience

Nice To Haves

Master’s degree in nursing or related field
Certification in specialty area i.e. URAC (Utilization Review and Accreditation Commission) certification
Knowledge and understanding of utilization review and management
Leadership experience
Excellent customer service skills
Knowledge and understanding of utilization review and management concepts and practice
Group process and change management knowledge and skills
Strong leadership skills and works well with physician and members of the interprofessional team members
Flexible, organized and attention to detail

Responsibilities

Performs and documents preadmission, concurrent, and retrospective reviews of patient clinical records using pre-established, objective criteria
Enhances performance improvement and quality outcomes, and ensures safe patient care.
Completes admission, observation status and continued stay discharge reviews and documents reviews in the electronic health record. All reviews will be completed within 24 hours or on the first business day after admission.
Works collaboratively with medical staff and providers to determine and assign proper status for all inpatients.
Monitors incomplete status reports and completes follow up.
Provides insurance utilization review and care management staff with routine updates on patient’s condition and progress.
Serves as internal consultant regarding utilization review and management of patients within the hospital setting.
Performs daily interprofessional rounds to coordinate the optimal patient care experience.
Facilitates daily discussion and tracking of discharge goals, anticipated discharge dates and progress towards the goals.
Works collaboratively with the health care team to help break down any barriers to prevent a planned discharge of a patient.
Assists team member is assessing proper status of patient and reviewing documentation to support the proper status.
Coordinates, monitors and reviews other activities as needed.
If insurance denies payment for care, works collaboratively with medical staff and family to appeal decision and advocate for patient needs.
Participates in activities that promote professional growth and quality improvement.
Monitors, analyzes and develops plans to improve key metrics for process improvement as agreed upon by the UR/UM committee on an annual basis
Completes all annual education requirements within the last evaluation cycle; demonstrate knowledge by performing all aspects of job in accordance with safety policies.
Ongoing training to maintain competence in utilization review and management skills.
Engages in the practice of Financial Stewardship.
Analyzes data and make recommendations to change medical practice to enhance efficiency.
Acts as liaison between fiscal and clinical areas and provides data to maximize reimbursement.