Description

Under general supervision, the Utilization Review Case Manager (UR CM) performs review of patient charts as defined by the Hospital's Utilization Review Plan. The UR CM validates the patient’s admission status and level of care to be at the most appropriate based on nationally accepted admission criteria. The UR CM uses medical necessity screening tools, such as MCG criteria to complete initial and continued stay reviews in determining appropriate admission and continued stay status and level of patient care. The UR CM secures authorization for the patient’s clinical services through collaboration and communication with 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

Adheres to policies, procedures, and standards of practice to deliver safe and optimal care Complies with Joint Commission’s national patient safety goals Complies with organizational quality dashboard/benchmarking goals Maintains regulatory compliance consistent with quality standards and ethical obligations of the profession Participates in activities in alignment with the Magnet Model Participates in organizational committees, task forces and/or projects including presentation of project reports, committee recommendations, and task force activities at the unit level. Participates in Peer Review Participates in professional development activities Provides patient and family education throughout the care of patient Performs as a preceptor in an active and engaged manner Provides age specific and culturally competent discharge planning to all patients.