Utilization Review-Care Management Coordinator Pt/Day

JOB SUMMARY: Under the direct supervision of the Manager of Case Management and Social Services, the Care Management Coordinator (CMC) serves as a liaison among all disciplines including Administration, Medical staff, HIM, Nursing, and Finance.

The CMC works collaboratively with the MMHS health care team to achieve best practices, discharge planning, clinical documentation and utilization management functions. The CMC strives to create improvements in clinical and cost-efficiency of health care that is delivered at MMHS. These duties will be performed in adherence to the missions, visions and values of MMHS.

Accurately and timely plans, coordinates, and implements cost-effective, comprehensive, multidisciplinary plan of care for each patient, which meets employee physical, functional, psychological, social, environmental, and financial needs. Reviews patient medical records to assure medical necessity of admission and appropriateness of length of stay for all patients.

PERFORMANCE DIMENSIONS AND TASKS

Essential Function

1.Case Management

a. CMC collects data and recommends change based on that data. Prepares utilization review reports; distributes according to established procedures.

b. Tracks and trends avoidable days.

c. Follows regulatory licensing and accreditation standards applicable to the UR function.

Demonstrates thorough working knowledge of applicable regulations and guidelines. Ensures that utilization review procedures comply with applicable regulatory and accreditation standards.

d. Staff education. This includes administration, physicians, and nursing staff regarding documentation for admission guidelines, medical necessity, length of stay, admission status, plan of care, etc.

e. Co-chairs UM Committee.

f. Assists the manager of CMC in creating the agenda and obtaining data.

g. Assists with agenda planning for the Utilization Review Committee meetings.

h. Coordination of care activities:

i. Demonstrates abilities through the continuum of care by recognizing inappropriate admissions and premature discharges.

j. Oversees individual patient progress toward desired outcomes.

k. Identifies and refers situations needing psychosocial intervention to appropriate social services staff.

l. Process Improvement

m. Identifies and communicates process improvement opportunities for: inappropriate admissions, delays in service and delays in discharge.

n. Participates in process improvement efforts.

2.Utilization Management

a. Independently performs concurrent and retrospective review of all patient cases using InterQual criteria. Discusses cases as appropriate with the attending physician, or the physician advisor.

b. Ensures appropriate patient status assignments for all admitted patients.

c. Reviews for medical necessity on all patients' admissions and appropriate length of stay within 24 hours of admission.

d. Maintains working knowledge of regulations and third party provider contracts governing the coverage of inpatient services.

e. Reviews Medi-Cal patient charts and receives inpatient stay authorizations, by completing eTAR's (Electronic Treatment Authorization Requests).

f. Refers all cases which are unclear/questionable or which require attending physician documentation to designated Physician Advisor.

g. Ensures Admission Denial letter of the ineligible admit is routed to patient and attending physician prior to admission or in a timely manner.

h. Reports and makes recommendations related to Utilization Management Committee activities to the appropriate medical staff and Quality Review committees.

3.Denials Management:

i. a. In collaboration with HIM and PFS the CMC will assist in the management of denied cases.

j. b. Maintains PRO/other reviews and denied reimbursement cases.

k. c. Assists physicians with appeal of denied reimbursement where appropriate; takes follow up action.

d. Attempts to reverse admission denials; provides documentation, persuasion and follow up to justify admission.

Correspondence is current.

e. Routinely reviews medical records of denied and complicated admissions to retrospectively determine potential

length of stay.

4.Discharge Planning

a. Coordinates utilization and discharge planning with all patient care staff.

b. Implements and maintains effective communication system and liaison with physicians, clinic and ancillary staff to ensure maintenance of utilization and discharge planning objectives.

QUALIFICATIONS

Education:

• Successful completion of an accredited Nursing Program - required

• Bachelor of Science in Nursing and Case Management certification - preferred

Work Experience:

• Minimum of three years recent acute care clinical nursing experience - preferred

• Minimum of three years recent case management or discharge planning experience - preferred

Skills Requirements:

• Utilizing the nursing process, review medical treatment and make suggestion to the care team.

• Assess and demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served on the assigned units/departments.

Licensing Requirements:

• Current California RN License - required

• Current AHA BLS - required

Language Requirements:

• Bilingual (English/Spanish) - preferred

Physical Demands:

• Must be able to sit up and stand/walk up to eight hours.

• Must be able to lift and push up to 10 pounds.

• Must be able to use hands repetitively for six hours or more.

Special Demands:

• Ability to supervise and work cooperatively with others.

• Must be able to delegate duties and maintain efficient standards of operation.

DISCLAIMER: The preceding job description has been designed to indicate the general nature and level of work performed. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.