General Summary of Position: The Emergency Department Case Manager / Utilization Review Nurse collaborates with all members of the Emergency Department/Clinical Resource Management (CRM) team to review and coordinate the admission of Emergency Department patients; and is available on a rotating basis on weekends, evenings, and holidays with other staff to provide onsite services for Utilization Review or Case Management. Initiates appropriate clinical pathways based upon diagnosis and serves as a resource person for utilization management purposes as well as partnering with the Social Worker Team to promote smooth transitions for discharge planning. Education: Bachelor#s degree along with current District of Columbia RN license is required. Experience: Two years minimum experience working in Case Management or/and Emergency Department Case Management experience. Knowledge of Medicare, Medicaid, and Third Party payor programs. Certification/Registration/Licensure Current RN District of Columbia license, CPR, and BLS are required. Certified Case Manager is preferred.
Under the direction of The Director of UM/Appeals assists in the administration of utilization functions, the Utilization Review Nurse, assesses patient insurance/status to facilitate appropriate completion of utilization review using payer specific criteria; uses Interqual and MCG to determine medical necessity and appropriateness of inpatient or observation status ; serves as communication liaison between registered nurse case managers, social workers, on-site reviewers, patient financial services, outpatient areas and registration; and performs all functions in accordance with all applicable laws, regulations and MedStar Washington Hospital Centers philosophy, policies and standards.
Bachelors degree along with current RN DC license is required. However, an Associates degree in Nursing with five years of bedside nursing experience can be used in lieu of the Bachelors degree requirement. Familiarity using a personal computer including word processing and spreadsheets is required. Knowledge of reimbursement models (commercial, managed care, Medicare) is preferred.
Three to five years experience as a clinical nurse in an acute care setting. Prior experience in a hospital or office type setting preferred, prior experience as a Case Manager. Knowledge of MS Office Suite required. Insurance/payer experience preferred/prior utilization review experience preferred. Proficiency in Allscripts, MCG and InterQual preferred.
On The Job Experience
Approximately six months to gain familiarity with the hospital environment, department routines and procedures and full range of duties.
Licensure as a registered nurse in the District of Columbia is required.
Knowledge, Skills & Abilities
PROBLEM SOLVING Ability to establish priorities, meet deadlines and maintain standards of productivity.
INTERNAL CONTACTS Internal contacts necessary to effectively advise, consult or counsel others to gain cooperation and acceptance of ideas or actions.
INDEPENDENT JUDGEMENT Work assignments are generally received in the form of results expected, due dates, and general approach to be taken. Ability to incorporate clinical skills, theoretic concepts and knowledge of costs in determining effective and appropriate course of action.
Primary Duties and Responsibilities
Consistently meets baseline productivity standards of 35 utilization reviews daily.
Applies MCG criteria or InterQual and advanced clinical knowledge to determine medical necessity, appropriate level of care, appropriate resource utilization, optimal insurance coverage and timely discharge.
Takes appropriate action when level of care determinations are not in alignment with clinical information, clinical criteria or third party information.
Validates admission and continuing stay criteria with third party payers and Attending Physicians.
Collaborates on a daily basis with the CRM unit team to discuss patients ready for discharge, possible insurance issues, and patient status changes and identified barriers that might impact LOS.
Maintains accurate, concise, and timely documentation in Allscripts or case management database and other WHC record-keeping systems according to Department and Hospital standard practice.
Maintains current knowledge of clinical treatment modalities related to assigned patient populations, quality and clinical improvement strategies, and reimbursement issues.
Identifies consistent actual and/or potential issues related to quality, length of stay and reimbursement, and communicates them to department leadership using established procedures.
Assists with departmental projects and other functions as assigned to support department operations and/or assist with patient specific issues that may arise.
Provides functional assistance to include:
Working with case managers, social workers, management teams and other groups as necessary to identify and manage utilization issues that impact hospital revenues.
Working collaboratively with Director of Appeals/UM, Social Work and Director of CRM to problem solve core issues which may cause delays in hospital reimbursement.
Making follow-up calls.
Preparing written appeals to facilitate the denials process.
Escalates issues to utilization leadership as required.
Participates in committees as required.
Performs other related duties as assigned.
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