Utilization Care Manager

Brown Medicine • Providence, RI

5d • Onsite

About The Position

The Utilization Care Manager reports to the Director of Care Management or designee and is responsible for conducting surveillance over the medical necessity of patient care records. This role collaborates with the physician of record and the Utilization Review Committee physician to ensure the appropriate level of patient care is provided and that admission and concurrent authorizations from third party payers are obtained. The goal is to ensure appropriate and timely utilization of resources and services so that patients receive high quality, safe, and fiscally responsible care. Brown University Health employees are expected to role model the organization's values of Compassion, Accountability, Respect, and Excellence, and demonstrate the core Success Factors: Instill Trust and Value Differences, Patient and Community Focus, and Collaborate.

Requirements

• Licensure as Registered Nurse in the State of Rhode Island by the Rhode Island Board of Nursing or licensure as a Registered Nurse in accordance with the Nurse Licensure Compact agreement of the National Council of State Boards of Nursing.
• Bachelor’s degree in Nursing with current license to practice as a Registered Nurse in the State of Rhode Island.
• Five years’ clinical experience with recent experience in utilization review, case management, patient navigation or discharge planning is strongly preferred.
• Strong analytical and interpersonal skills are required to provide guidance to and communicate daily with healthcare professionals, patients and families.
• Must exhibit a collaborative approach and method of communication in order to interact successfully on a daily basis with a wide and diverse population of both health care providers, insurers, patients and their families.
• Familiarity with InterQual™ care management criteria is required, as well as a high level of knowledge concerning utilization review, healthcare finance and the requirements of relevant payers.
• Demonstrates knowledge and skills necessary to provide care to patients throughout the life span, with consideration of aging processes, human development stages and cultural patterns in each step of the care process.
• Must be proficient in the use of Microsoft Office software including email and Outlook calendar, and have basic keyboarding skills.

Nice To Haves

• Master’s Degree preferred.
• Certified Professional in Healthcare Management (CPHM) is highly desirable.

Responsibilities

• Demonstrates a fundamental grounding in nursing theory and practice with a clinical background within a defined content area.
• Remains current on the latest concepts, techniques, and methods relative to their service.
• Demonstrates knowledge of federal and state rules and regulations.
• Applies InterQual™ level of care screening criteria to all admissions within one business day of admission.
• Interacts with team and physicians to resolve any level of care discrepancies and ensures accurate documentation.
• Discusses with attending of record when patient level of care criteria is not met to discuss a plan of action.
• Reviews all admissions and proactively provides clinical information to third party payers to support level of care.
• Serves as a liaison with third party payers as necessary to clarify level of care questions.
• Reviews all Medicare patient admissions daily and ensures the appropriate level of care for patients per Medicare and insurance regulatory guidelines.
• Conducts concurrent reviews on all patients at a minimum of every three days to facilitate patient throughput during current episode of care, and to identify delays.
• Delivers Hospital Issued Notice of Non-coverage (HINN) to Medicare Beneficiaries when acute inpatient admission is not medically necessary or could be furnished in an alternative setting.
• Initiates and completes concurrent expedited patient appeals and advises patients of insurers’ response, provides guidance and counsel on the appeal process and their care options.
• Provides education to members of the healthcare team regarding Medicare and regulatory guidelines regarding appropriate levels of care, the HINN delivery and the patient appeal process.
• Acts as a liaison with the Care Coordination Manager to discuss approaching discharge readiness of patients.
• Reviews and acts as a change agent by identifying opportunities to improve patient flow, and identifies and reduces service delays through problem resolution and follow-up.
• Identifies and tracks service and discharge patient delays.
• Promotes patient satisfaction by proactively providing clinical information to third party payers to ensure authorization for hospital services and conducting expedited appeals of denied services in collaboration with the patient’s physician of record.
• Ensures the appropriate level of care is assigned to patients upon admission in the Emergency Department.
• Responsible for the identification of Medicare Beneficiaries that require Hospital Issued Notices of Non Coverage (HINN).
• Responsible for delivery of appropriate notices as indicated and advises patient of appeal rights and care options.

Benefits

• Equal employment opportunities
• Work environment free from all forms of unlawful discrimination and harassment
• Respectful, inclusive, and equitable environment that supports the holistic well-being of our employees and their families

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level