RN, Utilization Review Case Manager II
About The Position
This position assists in the development, implementation, and revision of the utilization management program. It monitors adherence to the hospital's utilization review plan to ensure effective and efficient use of hospital services and reviews the appropriateness of hospital admissions and extended hospital stays. The role performs utilization review in accordance with all state and federal mandated regulations and maintains compliance with regulation changes affecting utilization management. The position works collaboratively with all interdisciplinary staff internal to OhioHealth and also external organizations to achieve timely, cost-efficient, and effective management of patient care.
Requirements
- Bachelor's Degree (Required)
- BLS - Basic Life Support - American Heart Association
- CPI - Crisis Prevention Intervention - Crisis Prevention Intervention
- Graduate from an accredited Bachelor's of Nursing Program
- Current State of Ohio RN licensure
- Familiarity with computer technology, and ability to use database and spreadsheets
- Excellent written/verbal communication and teaching/training skills
- Demonstrated success in achieving or exceeding measurable performance criteria in a job setting.
- Three or more years of clinical Experience within hospital or payer setting.
- BSN or 15 yrs of nursing experience at OhioHealth.
Nice To Haves
- If in the Behavioral Health Department, must have Basic Life support (BLS) and Crisis Prevention Intervention (CPI) obtained with in the first 30 days of hire and must remain current.
- Case Management Certification within first year.
Responsibilities
- Reviews all patients' medical records and assigns status following Interqual/mcg guidelines.
- Obtains and reviews necessary physician orders, medical reports and subsequent treatment plans to conduct review.
- Monitors observation status and outpatient occupying a bed for medical necessity criteria and communicates with members of the healthcare team to ensure timely orders for appropriate changes in level of care.
- Refers to designated Physician Advisor those patients not meeting severity of illness and intensity of service for acute care.
- Performs concurrent review on medical records and participates in interdisciplinary collaboration with professional staff.
- Communicates with third party payers and sends appropriate clinical information for authorization of hospital stay.
- Receives and processes requests for appeal of denials.
- Ensures appropriate and cost-effective healthcare services to patients.
- Actively participates in development, implementation and ongoing evaluation of the utilization management program.
- Facilitates and/or develops educational programs and advises physicians and other departments of regulations affecting utilization management, efficient allocation of resources, and appropriate length of stay.
- Monitors quality and type of services delivered to patients, ensuring management within established parameters.
- Actively participates in program development and quality improvement process to ensure quality outcomes.
- Acts as preceptors to new hires.
- Responsibilities require focus on safety, quality and efficiency in performing job duties.
Benefits
- Great Place to Work CertifiedTM organization
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What This Job Offers
Career Level
Mid Level
