Utilization Review Case Manager -Registered Nurse

Island Health Careers•Anacortes, WA

1d•Onsite

About The Position

This role focuses on discharge planning and utilization review within a hospital setting. The Utilization Review Case Manager - Registered Nurse is responsible for assessing patients' post-hospitalization needs, coordinating referrals, and ensuring safe and cost-efficient continuity of care. This involves managing daily workloads, prioritizing patient assessments, and documenting all interventions and planning. The position also includes performing medical record reviews for third-party payers and assessing the medical necessity of hospital admissions and continued stays. Collaboration with physicians, payors, and community resources is essential, as is educating patients and families about transition planning. The role requires strong analytical, problem-solving, and critical thinking skills, along with proficiency in computer systems and communication with various stakeholders.

Requirements

Minimum of three (3) years’ experience in a hospital setting with medical/surgical experience; may have equivalent combination of education and/or experience.
One (1) year experience in discharge planning, case management and/or utilization management experience.
Must maintain active RN license issued by the WA Department of Health.
Graduate of an accredited school of nursing.
Strong verbal, written and interpersonal communication skills.
Strong organization skills with the ability to work independently or as part of an interdisciplinary team in a fast-paced environment.
A high level of maturity, professionalism and discretion in daily interactions with patients, families and interdisciplinary team.
Timely and effective communication with patients, families, providers and interdisciplinary team.
Assure excellent customer service is provided to all stakeholders inside and outside the organization.
Knowledge of discharge planning, utilization review, CMS criteria related to patient status and general payor reimbursement requirements.
Strong analysis/problem solving skills.
Computer skills to include proficiency in keyboarding and data entry.
Critical thinking skills, able to assess, evaluate and teach.
Requires sitting and standing associated with a typical office environment.
Should have the hand-eye coordination and manual dexterity needed to operate a keyboard, photocopier, telephone.
Normal range of hearing and eyesight to record, prepare and communicate appropriate reports are required.
Close vision, distance vision, color vision, peripheral vision, depth perception and the ability to focus.

Nice To Haves

Advanced education to include BSN preferred.
MS Office proficiency preferred.

Responsibilities

Identifies patients at risk for problems post-hospitalization through comprehensive assessment of discharge needs.
Facilitates referrals to appropriate discipline/team members and outside agencies for safe and appropriate discharge plans.
Identifies community resources and coordinates referrals.
Prioritizes and manages daily workload, analyzing and evaluating assigned caseload.
Assesses patients requiring initial or ongoing discharge assessment, readmission risk assessment, or discharge plan.
Determines which patients are discharging and need post-hospital placement and continued follow-up care.
Assures timely and appropriate documentation of discharge and risk assessments, discharge plan, utilization management, and follow-up care.
Works with patients and interdisciplinary care team members to coordinate and implement patient discharge planning.
Collaborates with community resources and acts as a liaison between Care Management and agencies.
Communicates patient discharge plans with appropriate stakeholders.
Documents all assessments, interventions, and planning clearly, concisely, accurately, and in a timely manner.
May perform initial and concurrent medical record review for third-party payers.
May review medical records for medical necessity of hospital admission and continued stay using Interqual or other assigned guidelines.
Educates and includes patients and families in transition planning for discharge and provides updates throughout the hospital stay.
Contacts and arranges placements to skilled nursing facilities, rehab, long-term care, specialty care, and home health agencies.
Performs prospective, concurrent, and retrospective reviews to determine medical necessity of patient level of care in collaboration with Physician Advisor and commercial payors.
Performs Risk Assessment for all new admissions to determine the need for assignment to Discharge Planning for a comprehensive face-to-face patient assessment to identify and plan for an appropriate discharge plan.