Utilization Management RN

Innova Solutions•Philadelphia, PA

18h•Onsite

About The Position

Innova Solutions has a client that is immediately hiring for a Utilization Management RN. This is a Part Time – Contract to hire position with a duration of 03 Months, located in Philadelphia, PA. As a Utilization Management RN, you will perform telephonic utilization management for inpatient admissions. Using the medical software criteria, you will establish the need for inpatient, continued stay and length of stay. You will direct the delivery of care to the most appropriate setting, while maintaining quality. You will contact attending physicians regarding treatment plans/plan of care and clarify the medical need for inpatient stay or continued inpatient care. You will identify inpatient admissions that no longer meet criteria and refer care to plan Medical Directors for evaluation. You will present cases to Medical Directors that do not meet established criteria and provide pertinent information regarding members’ medical condition and the potential home care needs. You will perform early identification of hospitalized members to evaluate discharge planning needs. You will collaborate with hospital case management staff, physicians and family to determine alternative settings at times and provide support to facilitate discharge to the most appropriate setting. You will identify and refer for case management and disease management. You will identify quality of care issues including delays in care. You will appropriately refer cases to the Quality Management Department and/or Care Management and Coordination Supervisor when indicated. You will maintain the integrity of the system information by timely, accurate data entry. Utilization decisions are in compliance with state, federal and accreditation regulations. You will work to build relations with all providers and provide exceptional customer service. You will report potential utilization issues or trends to designated supervisors and provide recommendations for improvement. You will participate in the process of educating providers on managed care.

Requirements

Active PA RN license or compact license to include PA.
Minimum of three (3) years of acute care clinical experience in a hospital or other health care setting.
Prior discharge planning and/or utilization management experience.

Nice To Haves

Responsibilities

Perform telephonic utilization management for inpatient admissions.
Using the medical software criteria, establish the need for inpatient, continued stay and length of stay.
Directs the delivery of care to the most appropriate setting, while maintaining quality.
Contacts attending physicians regarding treatment plans/plan of care and clarifies medical need for inpatient stay or continued inpatient care
Identifies inpatient admissions no longer meet criteria and refers care to plan Medical Directors for evaluation.
Presents cases to Medical Directors that do not meet established criteria and provides pertinent information regarding members’ medical condition and the potential home care needs.
Performs early identification of hospitalized members to evaluate discharge planning needs.
Collaborate with hospital case management staff, physicians and family to determine alternative settings at times and provide support to facilitate discharge to the most appropriate setting.
Identifies and refers for case management and disease management.
Identifies quality of care issues including delays in care.
Appropriately refers to cases to the Quality Management Department and/or Care Management and Coordination Supervisor when indicated.
Maintains the integrity of the system information by timely, accurate data entry.
Utilization decisions are in compliance with state, federal and accreditation regulations.
Works to build relations with all providers and provides exceptional customer service.
Reports potential utilization issues or trends to designated supervisors and recommendations for improvement.
Participates in the process of educating providers on managed care.