Utilization Review Case Manager
Job Summary and Scope
The Utilization Review Nurse performs utilization review of all patients presenting for hospitalization to assist in identifying patients appropriate for admission to inpatient, observation, or other patient care status. This position conducts admission reviews, continued stay review, and retro reviews evaluating the medical necessity, appropriateness and efficient use of health care services of all hospitalizations, inpatient or outpatient/observation. The Utilization Review Nurse collaborates with physicians, the health care team and case managers to optimally certify the level of care and facilitate the patients movement through the continuum of care as appropriate.
POLICIES AND PROCEDURES - Maintain established departmental policies and procedures, objectives, and quality assurance programs
PROFESSIONAL DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops.
Demonstrates expertise in the application of MCG criteria.
Review of clinical data for ED admissions, and direct admissions, making level of care recommendation to the assigned physician and obtaining any additional clinical information that may assist in determining appropriate level of care. Serves as a resource for facilitating patient transfers, including, but not limited to, obtaining or providing clinical information from/to the referring/accepting facility and performing clinical reviews of all inbound transfers for appropriateness.
Ensures operative procedure performed is the operative procedure prior-authorized with the third party payer and communicates any variance.
Identifies high risk social issues and refers to Case manager or Director of Case Management as appropriate. Collaborates with the case manager to ensure appropriate level of care. Actively participates in the multidisciplinary team meetings as needed. Identifies, track, and documents delays in service
Monitors use of healthcare resources. Communicates with physicians to assure patients receive diagnostics/evaluations in the proper setting, i.e. inpatient vs outpatient
Communicates openly with third party payers and works collaboratively with them to avoid admission and concurrent review denials. Maintains current knowledge of CMS (Medicare) rules and regulations.
Serves as an expert resource to physicians and healthcare staff in the application of MCG criteria and the use of evidence based practices.
Conducts initial (admission) reviews at the time of presentation, or within 24 hours of admission. If patient presents during uncovered hours, review will be completed next business day. Conducts concurrent review per department policy (every three days for Medicare unless the patient condition changes), and as private payer dictates. Conducts and monitors observation reviews daily.
Follows department policy regarding escalation of utilization issues to the Physician Advisor, Director of case management or his/her designee.
Perform miscellaneous job-related duties as assigned.
SRMC Core Values
Integrity: Our words and actions match our values
To Serve: We put the needs of others before our own
Excellence: We strive to exceed expectations and/or standards in every activity, every encounter, and every initiative
Safety/Quality: We provide evidence based care, programs, services, and an environment that achieves the best outcomes
Teamwork: We enjoy the ability and power to work collaboratively to deliver exceptional service
Maintain state and federal regulatory standards relating to utilization management and discharge planning.
Coordinate effective patient through put and enhance appropriate utilization of services in accordance with Length of stay (LOS) benchmarks
Valid New Mexico Registered nurse license
Knowledge of Medicare and Medicaid regulatory requirements and Joint commission standards
Knowledge of insurance provider and other third party payers.
Knowledge in Interqual or Milliman care guidelines
Knowledgeable in computer skills, Microsoft Word, Excel, Outlook, Cerner, Epic and Case management systems as Curaspan, Midas, Allscripts
Must have experience in performing utilization review
Must be able to multitask and work independently
Education: Graduate of an accredited school of nursing
Licenses/Certifications: Registered nurse license in the state of New Mexico
Work Experience: : 1 year utilization management or 2 years medical surgical/telemetry/ICU experience
Case Management Certification (CCM) ,American case management association certification (ACM), Utilization management or utilization review certification (CPUM/CPUR) preferred or at least 3 years after hire
Conditions of Employment
Must pass a pre-employment criminal background check, reference checks and a post offer drug screen.
Must be employment eligible as verified by the U.S. Dept. of Health and Human Services Office of Inspector General (OIG) and the Government Services Administration (GSA).
Tuberculin Skin Test required annually
Hospital required vaccinations
Hospital required competencies
Typical office and/or patient care, acute care hospital environment.
Must be able to travel locally between facilities and within the surrounding community.
Occasional exposure to minimal physical risk
UNM Sandoval Regional Medical Center