Utilization Review Case Manager - FT Days

Torrance Memorial Medical Center•Torrance, CA

11d

About The Position

Under general supervision, the Utilization Review Case Manager reviews patient charts according to the hospital’s Utilization Management Review Plan and validates that patients are placed at the most appropriate level of care using nationally accepted admission criteria. The role uses medical necessity screening tools such as InterQual or MCG to perform initial and continued-stay reviews, and collaborates and communicates with payers to secure authorization for clinical services. The case manager follows the Utilization Review process in accordance with the CMS Conditions of Participation for Utilization Review. The position works with patients, families, medical staff, RN Case Managers, Physician Advisors, external case managers, and payers throughout the continuum of care. It supports appropriate patient status and placement, discharge planning, denial prevention and management, and compliance with applicable requirements and organizational quality goals.

Requirements

Bachelor’s degree in Nursing.
Registered Nurse license.
At least 1 year of experience in acute hospital case management or Health Plan Utilization Review.
At least 2 years of clinical experience in an acute care facility.

Responsibilities

Review patient charts according to the hospital’s Utilization Management Review Plan and validate the appropriate level of care using nationally accepted admission criteria.
Use medical necessity screening tools, including MCG criteria, to perform initial and continued-stay reviews and document reviews daily.
Collaborate and communicate with payers to obtain service authorizations, provide initial reviews and updates, and communicate anticipated discharge-planning needs.
Assess the need for home durable medical equipment, follow up with home health, and communicate anticipated needs to payers.
Work with RN Case Managers and Physician Advisors to facilitate peer-to-peer reviews and help mitigate potential denials.
Communicate with patients, families, medical staff, external case managers, and other parties during the continuum of care.
Ensure physician admission and patient-status orders are valid and reflect the appropriate level of care.
Identify and monitor observation cases daily; identify inappropriate bed utilization, quality-of-care concerns, delays, and obstacles, and refer concerns to the appropriate parties, including the Utilization Management Physician Advisor.
Facilitate transfers to other facilities.
Complete Medi-Cal TAR submissions during the patient’s stay according to DHS requirements.
Attend the denial management committee; document denial information, coordinate delivery of denial letters with RN Case Managers, research denied claims, and submit additional clinical information for reconsideration or refer cases to the Physician Advisor.
Review commercial accounts daily, or as required by contract or payer expectations; conduct retrospective reviews and chart reviews and quality assessments as directed.
Track avoidable days and maintain Blue Cross Hold under $2 million daily.
Maintain working knowledge of Medicare patient-status requirements, including the Two-Midnight Rule and Inpatient Only List.
Assist with orientation and competency assessment of new or transferred employees.
Maintain clear, concise documentation and comply with applicable laws, regulations, Joint Commission patient safety goals, and organizational quality dashboard and benchmarking goals.
Demonstrate culturally competent care, good customer relations, effective communication, independent judgment, initiative, time management, organization, and prioritization.
Develop and maintain cooperative relationships with hospital personnel, physicians, suppliers, and insurance case managers; follow up by phone to answer questions and resolve problems.
Evaluate the work environment and make positive suggestions for change.
Role-model excellent customer service to support the patient experience.