Utilization Review Case Manager -Registered Nurse

Island Health•Anacortes, WA

2d•$38 - $58•Onsite

About The Position

This position is responsible for discharge planning and utilization review within a hospital setting. The Utilization Review Case Manager - Registered Nurse will identify patients at risk for post-hospitalization problems, assess their discharge needs, and facilitate referrals to appropriate team members and outside agencies. The role involves coordinating and implementing patient discharge plans, communicating with stakeholders, and documenting assessments and interventions. Additionally, the position performs medical record reviews for third-party payers and assesses the medical necessity of hospital admissions and continued stays using established guidelines. The role also involves risk assessment for new admissions to determine the need for discharge planning and comprehensive patient assessments to identify and plan for appropriate discharge. Collaboration with the Physician Advisor and commercial payors is essential for prospective, concurrent, and retrospective reviews to determine medical necessity.

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; advanced education to include BSN preferred.
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.
MS Office proficiency preferred.

Nice To Haves

advanced education to include BSN preferred

Responsibilities

Identifies patients at risk for encountering problems post-hospitalization through performing a comprehensive assessment of patient discharge needs and assists to facilitate a referral for appropriate discipline/team members and outside agencies for facilitating safe and appropriate discharge plan.
Identification of community resources and coordination of referral.
Ability to prioritize and manage daily workload. This includes the ability to continually analyze and evaluate daily assigned caseload and prioritize the patients that require an initial or on-going discharge assessment, readmission risk assessment or discharge plan, which patients are discharging and need post-hospital placement and continued follow-up care needs.
Assure timely and appropriate documentation of discharge and risk assessments, discharge plan, utilization management and follow-up care to assure safe and cost efficient continuity of care.
Works with patient and interdisciplinary care team members to coordinate and implement patient discharge planning.
May collaborate with community resources and be a liaison between Care Management and agencies as appropriate for the benefit of discharge planning.
Communicates patient discharge plan with appropriate stakeholders.
Documents clearly all assessments, interventions and planning in a clear, concise, accurate and 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.
Educate and include patient and family in transition planning in preparation for discharge and provides updates and/or changes throughout the hospital stay.
Contact and arrange placements to skilled nursing facilities, rehab, long-term care, specialty care, home health agencies.
Works in collaboration with Physician Advisor and commercial payors to perform prospective, concurrent and retrospective reviews to determine if patient level of care is determined to be medical necessary.
Performs Risk Assessment for all new admissions to determine need for assignment to Discharge Planning for a comprehensive face to face patient assessment to identify and plan for appropriate discharge plan.
Other duties as assigned dependent upon training and scope of practice.