Description

Under general supervision, performs review of patient charts as required by the Hospitals Utilization Management Review Plan. The Utilization Review Case Manager (UR CM) validates the patient's placement to be at the most appropriate level of care based on nationally accepted admission criteria. The UR CM uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial (if not complete) and continued stay reviews in determining appropriate levels of patient care. The UR CM secures authorization for the patient's clinical services through collaboration and communication with the payers as required. The UR CM follows the UR process as defined in the Utilization Review Plan in accordance with the CMS condition of Participation for Utilization Review.

Core Competencies

Anticipates and assesses and informs payers of patient's discharge planning needs. Assesses need for home durable equipment, follows-up with home health and include(s) anticipated need in communication with payers Assists and supports a new or transferred employee through a planned orientation. Assists with the orientation and competency assessment of staff. Attends denial management committee. Collaborates with interdisciplinary and communicates this plan to the payer Collaborates with RN Case Managers and the Physician Advisors to facilitate the peer to peer process in order to mitigate potential denials Collaborates/communicates with external case managers. Communicates with the patient, family, medical staff and others during the continuum of care Completes all documentation in a clear, clean, concise manner. Complies with all applicable laws and regulations. Complies with organizational quality dashboard/benchmarking goals Complies with Joint Commission’s national patient safety goals Demonstrates culturally competent patient care. Demonstrates good customer relations skills. Demonstrates independent judgment, autonomy, initiative, time management and organizational skills and the ability to prioritize projects/functions in a busy work environment. Demonstrates knowledge of clinical norms for the different age groups as applicable to job functions. Develops and maintains cooperative relationships with hospital personnel, physicians, suppliers and insurance case managers. Demonstrates interpersonal communication skills that enable exchange of ideas and information effective with patients, families, and colleagues of all levels Documents daily using MCG criteria. Ensures optimal customer service/patient experience by role modeling excellent customer service Ensures the physician writes an order to admit the patient to appropriate level of care along with nursing, verify the physician writes a valid patient status order. Evaluates and makes positive suggestions for change in the environment. Follows up with a phone call in order to answer questions, problem solve. Facilitates transfer to other facilities. Follows up with Medi-Cal TAR submission during the patients stay according to the DHS requirement. Gives initial review and updates to insurance provider. Identifies and monitors Observation cases on a daily basis. Identifies and resolves delays and obstacles in collaboration with the RN Case Managers, nursing and the attending physicians Identifies inappropriate bed utilization and quality of care problems and refers them to Utilization Management physician advisor. Maintains Blue Cross Hold under 2 million dollars daily. Maintains working knowledge of Medicare requirements for patient status (Two-Midnight Rule, Inpatient Only List) Performs chart reviews and quality assessments on all patients using MCG criteria and secondary review as directed by Administration and the Medical Staff or as per contract or payer expectation (UR Committee). Performs retrospective reviews. Provides documentation for denial letter, collaborates with RN case manager for the delivery of denial letters to patients. Researches denial claims and submits additional clinical for reconsideration when appropriate, or refers to physician advisor for recommendation Reviews all commercial accounts daily or as per contract or payer expectation Tracks avoidable days.