Utilization Management Nurse II - Case Management

CHRISTUS Health•San Marcos, TX

1d•Onsite

About The Position

The Utilization Management Nurse II determines the clinical appropriateness of care and ensures appropriate use of hospital resources. The role performs pre-admission, concurrent, and retrospective utilization management reviews using approved screening criteria, including InterQual, MCG, and the CMS Inpatient List. The nurse manages a diverse workload in a fast-paced regulatory environment and maintains current knowledge of commercial and government payors and Joint Commission requirements related to utilization management. The nurse communicates with internal and external clinical professionals, coordinates insurance certification for services, and collaborates with the health care team to support patient care progression and appropriate levels of care. The position is based at CHRISTUS Santa Rosa Hospital – San Marcos and may involve travel to other facilities as needed.

Requirements

Graduate of an accredited School of Nursing, or at least five years of demonstrated success as a Utilization Management Nurse I at CHRISTUS Health in lieu of the education requirement, in addition to required experience.
Two or more years of clinical experience, including at least one year in an acute care setting, or demonstrated success as a Utilization Management Nurse I at CHRISTUS Health.
RN license in the state of employment or a compact RN license; an LPN or LVN license is accepted for associates with five or more years of demonstrated success and experience as a Utilization Management Nurse I at CHRISTUS Health.
Demonstrated clinical competency and sound clinical judgment.
Excellent verbal and written communication skills and ability to interact with diverse populations.
Critical and analytical thinking skills and ability to multitask in a stressful, fast-paced environment.
Working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
Understanding of pre-acute and post-acute levels of care and community resources.
Ability to work independently and exercise sound judgment when interacting with physicians, payors, patients, and families.
Negotiating skills to interact with physicians, nursing staff, administrative staff, discharge planners, and payers.
Knowledge of clinical protocols, normative data, and health benefit plans, particularly coverage and limitation clauses.
Ability to adjust to frequently changing workloads and interruptions.
Technology literacy and ability to work across multiple technology systems.

Nice To Haves

Familiarity with InterQual and MCG criteria sets.
Certification in Case Management.
BLS certification.

Responsibilities

Assess assigned patients for medical necessity, level of care, and appropriateness of the care setting and services.
Use MCG, InterQual, and other approved tools and criteria for admission, continued-stay, outlier, and clinical appropriateness reviews.
Coordinate correct identification of patient status and collaborate with physicians and treatment teams to obtain documentation supporting the level of care.
Facilitate interdisciplinary decision-making regarding patient status changes and negative patient outcomes.
Apply regulatory requirements, including IMM and Code 44, and follow applicable privacy requirements for protected health information.
Provide utilization review services and make timely determinations based on appropriate criteria and standards; take follow-up action when criteria are not met.
Refer cases to the Physician Advisor for medical necessity or peer-to-peer reviews and denial avoidance, and collaborate on secondary reviews.
Review patients at the point of entry to determine medical necessity and the appropriate level of care or placement.
Review surgery schedules to verify appropriate status and required authorization.
Review patients in Observation status to determine discharge appropriateness or whether conversion to inpatient status is warranted.
Identify and address clinical appropriateness, coverage, and potential or actual payor denial issues.
Communicate with payors and coordinate certification of hospital services in accordance with payor and regulatory requirements.
Coordinate patient care progression across the continuum and document medical necessity at each level of care.
Evaluate care provided by the interdisciplinary team, advocate for standards of practice, and analyze assessment data to identify problems and formulate goals or outcomes.
Attend department and interdepartmental meetings and participate in multidisciplinary or patient care progression rounds.
Document in the medical record according to regulatory and department guidelines; escalate cases to Physician Advisors or the CM Director as appropriate.
Use multiple technology systems and respond flexibly to organizational change and changing workloads.
May assist with special projects, serve as a preceptor or orienter, work overtime or take calls, and travel to other facilities as needed.
Maintain professional growth and development and perform other duties as assigned.