Registered Nurse (RN) Case Manager - Utilization Review - PT

Hutchinson Regional Medical Center, Inc.•Hutchinson, KS

About The Position

Collaborates with healthcare providers and members to assess general patient needs and benefit requirements in an effort to optimize resources. Manages patient case duties for the behavioral health unit. Essential Responsibilities: Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position. Reviews patients' situations and assesses the medical necessity of admissions, continued stays, and services provided for behavioral health patients. Conducts reviews to ensure compliance with eligibility, benefits, policy, and contracts. Manages appeals, and coordinates comprehensive reviews of patient medical records to ensure that they convey accurate information regarding admission and diagnosis. Assists in promoting improved quality of care, as well as decreased lengths of hospital stay when appropriate and safe. Advises pre-certification staff. Maintains records and prepares reports relating to non-clinical staff activities. Coordinate with insurance companies to secure authorizations for behavioral health services, ensuring compliance with payer requirements and facility standards. Maintain accurate documentation for all utilization review activities, including clinical justification and authorization requests. Assist with triage screenings for incoming behavioral health patients to determine immediate care needs and facilitate timely care delivery. Provide psychosocial support to patients and families, addressing emotional, social, and financial barriers to care. Act as a liaison between the healthcare team and patients/families to ensure smooth care transitions. Support discharge planning processes when the discharge planner is unavailable, ensuring a safe and appropriate discharge plan is in place for the patient (as needed) Assist with safety assessments and make necessary protective reports for adults and children when indicated. Participate in ongoing professional development and training, including de-escalation training and other mandatory certifications. Act in accordance with the established mission, vision, and values. Abide by the Health Insurance Portability and Accountability privacy and security regulations regarding all aspects of Protected Health Information (PHI). Maintain effective communication and professional working relationships with patients/clients and their representatives, team members, contractors, physicians, peers, outside agencies, and the public. General Responsibilities: Perform other duties as assigned.

Requirements

Graduate of nursing program or BSW program.
Experience in a behavioral health setting, particularly with crisis management and inpatient care.
Current licensure as a BSW or RN in the State of Kansas.
Current BLS card within 30 days of hire or by the end of orientation, whichever comes first. Acceptable courses are American Heart Association (AHA) or American Red Cross.
De-escalation training required within six months of start date
Ability to collaborate with interdisciplinary teams to ensure high-quality care.
Familiarity with community resources, mental health services, and post-acute care services.
Basic computer proficiency and ability to document in the electronic health record.
Completion of specific unit based and general hospital competencies.
Ability to apply the basic principles of patient care.
Demonstrated ability to communicate effectively.
Multi-tasking and prioritization skills.
Medium Work: Occasionally exerting up to 50 lbs - constantly exerting up to 10 lbs. 26-50% of the day may be standing or walking.

Nice To Haves

Experience in utilization review, insurance coordination, and interdisciplinary team collaboration
BSN or MSW

Responsibilities

Reviews patients' situations and assesses the medical necessity of admissions, continued stays, and services provided for behavioral health patients.
Conducts reviews to ensure compliance with eligibility, benefits, policy, and contracts.
Manages appeals, and coordinates comprehensive reviews of patient medical records to ensure that they convey accurate information regarding admission and diagnosis.
Assists in promoting improved quality of care, as well as decreased lengths of hospital stay when appropriate and safe.
Advises pre-certification staff.
Maintains records and prepares reports relating to non-clinical staff activities.
Coordinate with insurance companies to secure authorizations for behavioral health services, ensuring compliance with payer requirements and facility standards.
Maintain accurate documentation for all utilization review activities, including clinical justification and authorization requests.
Assist with triage screenings for incoming behavioral health patients to determine immediate care needs and facilitate timely care delivery.
Provide psychosocial support to patients and families, addressing emotional, social, and financial barriers to care.
Act as a liaison between the healthcare team and patients/families to ensure smooth care transitions.
Support discharge planning processes when the discharge planner is unavailable, ensuring a safe and appropriate discharge plan is in place for the patient (as needed)
Assist with safety assessments and make necessary protective reports for adults and children when indicated.
Participate in ongoing professional development and training, including de-escalation training and other mandatory certifications.
Act in accordance with the established mission, vision, and values.
Abide by the Health Insurance Portability and Accountability privacy and security regulations regarding all aspects of Protected Health Information (PHI).
Maintain effective communication and professional working relationships with patients/clients and their representatives, team members, contractors, physicians, peers, outside agencies, and the public.
Perform other duties as assigned.