Utilization Management Coordinator, Inpatient

Cook County•Chicago, IL

1d•$49 - $67•Onsite

About The Position

The Utilization Management Coordinator, Inpatient (UMC) serves an important role in supporting Cook County Health (CCH) goals of efficient, effective, patient-centric care. Using the electronic medical record (EMR) and consulting with the treatment team, the UMC determines if the patient is in the appropriate level of care and if clinical milestones are being met in a timely manner. The UMC provides timely feedback to the treatment team and makes appropriate referrals to other care coordination components for those patients who have barriers to discharge or whose condition requires a different level of care. The successful UMC has a sound clinical foundation, knowledge of utilization management, and critical thinking skills to support effective, timely communication regarding case status.

Requirements

Current License as a Registered Professional Nurse in the State of Illinois, is required.
Bachelor’s Degree in Nursing from an accredited college or university, is required.
Minimimum of three (3) years of acute care, medical surgical, and/or clinical experience as a registered nurse, is required.
Minimum one (1) year of experience in utilization management or clinical case management, is required.
Successful completion of an MCG Health Certification exam prior to starting employment, is required.

Nice To Haves

Masters degree in Nursing from accredited college or university, is preferred.
Knowledge of UM evidence-based practices, clinical practice guidelines, medical necessity criteria, and case management
Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age group
Demonstrated problem solving skills
Ability to adjust work pace to review demands
Excellent interpersonal skills, maintains demeanor
Ability to succinctly and accurately communicate case issues to relevant stake holders in a non-judgmental manner
Ability to prioritize work
Leverages technology to improve work flow

Responsibilities

Verifies payer status and medical home (documents same in notes)
Reviews cases being proposed for inpatient or observation at Stroger and Provident Hospitals within one hour of notification.
Provides continued stay review at intervals appropriate to the treatment plan and anticipated patient progress.
Translates signs, symptoms, lab values, diagnostic testing results, to a MCG guideline. For example, the UMC is able to discern the origin of shortness of breath based on history, clinical presentation, vital signs and test results to select the appropriate guidelines
Documents all relevant information in case notes
Detects and documents trends and in clinical and functional status data to assess patient progress
Correctly assigns medical necessity determination and level of care. If different than current assignment, notifies treatment team to alert them and provides recommendations.
Identifies and refers cases at risk: Readmissions within thirty (30) days, Failure to meet guidelines (either on initial or concurrent review), Multiple social determinants impacting care or treatment, Active MH or SUD, Those requiring on-going care coordination, Complex treatment plans, Managed Care Required care coordination, Planned re-admission requiring pre-certification
Uses portals to forward clinical information to payers
Communicates succinctly and efficiently with stakeholders such as insurance companies, physicians, Inpatient Care Coordination Specialist,
Monitors the process of obtaining pre-certifications and prior authorizations from insurance providers and third-party payers to ensure coverage for services.
Escalates cases when EMR documentation doesn’t support medical necessity requirement and outreach has not closed gaps.
Identifies and reports potential denial or delays in care to the Inpatient Care Coordination Manager
Supports and organizes peer-to-peer conversations to avoid potential denials.
Participates in departmental quality improvement guidelines
Completes all educational efforts for CCH and licensure
Conducts reviews of medical records to determine the medical necessity and appropriateness of admissions, continued stays, procedures, and discharge plans, using established guidelines like InterQual or MCG.
Verifies coverage for post-acute services (home health, rehab, DME)
Completes a minimum of forty-two (42) reviews per day (initial admissions and continued stay admissions)