Full Time: Monday-Friday (Opportunity for remote work following 6 month training period)
Boncura Health Solutions provides value based care services to physician groups and providers across the spectrum of care. Our biggest client is DuPage Medical Group, the largest and fastest growing independent physician group in the Midwest. We offer stability and career opportunities.
The Utilization Management Nurse is responsible for providing clinical expertise to providers and clients through the full continuum of care. This includes following inpatient, skilled nursing facility, acute rehab, long term acute care and home health cases to ensure that criteria is met, length of stay is appropriate, and discharge needs are in place, while staying within the parameters of compliance and regulatory requirements.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Performs initial and concurrent review on inpatient, skilled nursing facility, acute rehab, long term acute care and home health cases.
Determines medical necessity by application of criteria per Milliman Care Guidelines, Utilization Management Department Policies, specific Health Plan guidelines, and CMS regulations. Recommends an increase or decrease in level of care/equipment/service based upon medical condition and physician orders.
As a member of a multi-disciplinary team, provides assessment of the member or patient and family's psychosocial, medical and educational level in conjunction with hospital staff to assist in the discharge planning of hospitalized patient. This includes providing authorization for needed services through vendors in accordance with payer networks. Monitor ongoing planning process with medical team to ensure positive outcomes and timely transition to the next level of care. Document all pertinent information obtained through discussion with providers, patients, family members and other health care professionals in the EPIC tapestry record.
Confer with Medical Director and peers to resolve patient care problems and physician-related issues. Effectively communicate alternate service options when indicated.
Identify members who have ongoing case management needs, and refers these members to the Case Management team for outreach and follow up.
Coordinate and document the investigation of all potential quality of care/service issues in accordance with established policy and procedure.
Report findings to the UM/QA Committee and appropriate parties.
Support all Internal Quality Assurance initiatives developed for the Utilization Management Department. Report problems and negative patterns to the Manager and work with the manager to develop corrective action plans.
Participates in the preparation of all Health Plan audits.
Run reports, as needed, to review and analyze client data (i.e. Days/K, Admits/K, ALOS). 7. Attend monthly client Utilization Management Committee meeting(s) as assigned. Prepare monthly Utilization Management statistics and discuss cases, at the Utilization Management Committee meeting, that result in an increased length of stay due to medical complexities.
EDUCATION and / or CERTIFICATION/LICENSURE:
Current LPN or RN license in the State of Illinois
Case Management Certification (CCM or ACM) preferred
A minimum of 2 years experience providing clinical guidance and coordination as a UM or UR nurse.
A minimum of 2 years experience with discharge planning and care coordination through the continuum of care.
Experience with Milliman Care Guidelines or InterQual Guidelines used to determine medical necessity.
Experience working with Epic or other electronic medical record is required.
Prior experience with managed care guidelines, familiarity with Medicare Advantage strongly preferred.
Prior experience working in a health plan a plus
ABOUT DUPAGE MEDICAL GROUP
Join one of the fastest-growing healthcare teams in Chicagoland and experience what superior care and innovation is all about. DuPage Medical Group is the largest independent, multi-specialty physician group in the state, providing physician-directed healthcare focused on quality, efficiency and access. Our team is comprised of more than 600 experienced physicians and 4,000 dynamic individuals who work collaboratively to transform healthcare for the thousands of patients we serve each day. We seek candidates who can help fulfill our mission to enhance the well-being of the patients we serve by providing the highest quality medical care available.
Dupage Medical Group