Utilization Management Nurse II - Case Management
Company: Christus Health
Location: Tyler
Posted on: October 23, 2024
Job Description:
Description
Summary:
The Utilization Management Nurse II is responsible for determining
the clinical appropriateness of care provided to patients and
ensuring proper hospital resource utilization of services. This
Nurse is responsible for performing a variety of pre-admission,
concurrent, and retrospective UM related reviews and functions.
They must competently and accurately utilize approved screening
criteria (InterQual/MCG/Centers for Medicare and Medicaid Services
"CMS" Inpatient List). They effectively and efficiently manage a
diverse workload in a fast-paced, rapidly changing regulatory
environment and are responsible for maintaining current and
accurate knowledge regarding commercial and government payors and
Joint Commission regulations and guidelines related to UM. This
Nurse effectively communicates with internal and external clinical
professionals, efficiently organizes the financial insurance care
of the patients, and relays clinical data to insurance providers
and vendors to obtain approved certification for services. The
Utilization Management Nurse collaborates as necessary with other
members of the health care team to ensure the above according to
the mission of CHRISTUS.
Responsibilities:
- Meets expectations of the applicable OneCHRISTUS Competencies:
Leader of Self, Leader of Others, or Leader of Leaders.
- Applies demonstrated clinical competency and judgment in order
to perform comprehensive assessments of clinical information and
treatment plans and apply medical necessity criteria in order to
determine the appropriate level of care.
- Resource/Utilization Management appropriateness: Assess
assigned patient population for medical necessity, level of care,
and appropriateness of setting and services. Utilizes MCG/InterQual
Care Guidelines and/or health system-approved tools to track impact
and variance.
- Uses appropriate criteria sets for admission reviews, continued
stay reviews, outlier reviews, and clinical appropriateness
recommendations.
- Coordinate and facilitate correct identification of patient
status.
- Analyze the quality and comprehensiveness of documentation and
collaborate with the physician and treatment team to obtain
documentation needed to support the level of care.
- Facilitates joint decision-making with the interdisciplinary
team regarding any changes in the patient status and/or negative
outcomes in patient responses.
- Demonstrates, maintains, and applies current knowledge of
regulatory requirements relative to the work process in order to
ensure compliance, i. e. IMM, Code 44.
- Demonstrate adherence to the CORE values of CHRISTUS.
- Utilize independent scope of practice to identify, evaluate and
provide utilization review services for patients and analyze
information supplied by physicians (or other clinical staff) to
make timely review determinations, based on appropriate criteria
and standards.
- Take appropriate follow-up action when established criteria for
utilization of services are not met.
- Proactively refer cases to the physician advisor for medical
necessity reviews, peer-to-peer reviews, and denial
avoidance.
- Effectively collaborate with the Interdisciplinary team
including the Physician Advisor for secondary reviews.
- Proactively review patients at the point of entry, prior to
admission, to determine the medical necessity of a requested
hospitalization and the appropriate level of care or placement for
the patient.
- Review surgery schedule to ensure planned surgeries are ordered
in the appropriate status and that necessary authorization has been
obtained as required by the payor or regulatory guidance (i. e.,
CMS Inpatient Only List, Payor Prior Authorization matrix,
etc.)
- Regularly review patients who are in the hospital in
Observation status to determine if the patient is appropriate for
discharge or if conversion to inpatient status is
appropriate.
- Proactively identify and resolve issues regarding clinical
appropriateness recommendations, coverage, and potential or actual
payor denials.
- Maintain consistent communication and exchange of information
with payors as per payor or regulatory requirements to coordinate
certification of hospital services.
- Coordinate and facilitate patient care progression throughout
the continuum and communicate and document to support medical
necessity at each level of care.
- Evaluate care administered by the interdisciplinary health care
team and advocate for standards of practice.
- Analyze assessment data to identify potential problems and
formulate goals/outcomes.
- Follows the CHRISTUS Guidelines related to the Health Insurance
Portability and Accountability ACT (HIPPA) designed to prevent or
detect unauthorized disclosure of Protected Health Information
(PHI).
- Attend scheduled department staff meetings and/or
interdepartmental meetings as appropriate.
- Possesses and demonstrates technology literacy and the ability
to work in multiple technology systems.
- Act as a catalyst for change in the organization; respond to
change with flexibility and adaptability; demonstrate the ability
to work together for change.
- Translate strategies into action steps; monitor progress and
achieve results.
- Demonstrate the confidence, drive, and ability to face and
overcome challenges and obstacles to achieve organizational
goals.
- Demonstrate competence to perform assigned responsibilities in
a manner that meets the population-specific and developmental needs
of patients served by the department.
- Possess negotiating skills that support the ability to interact
with physicians, nursing staff, administrative staff, discharge
planners, and payers.
- Excellent verbal and written communication skills, knowledge of
clinical protocol, normative data, and health benefit plans,
particularly coverage and limitation clauses.
- Must adjust to frequently changing workloads and frequent
interruptions.
- May be asked to work overtime or take calls.
- May be asked to travel to other facilities to assist as
needed.
- Actively participates in Multidisciplinary/Patient Care
Progression Rounds.
- Escalates cases as appropriate and per policy to Physician
Advisors and/or CM Director.
- Documents in the medical record per regulatory and department
guidelines.
- May be asked to assist with special projects.
- May serve as a preceptor or orienter to new
associates.
- Assumes responsibility for professional growth and
development.
- Familiarity with criteria sets including InterQual and MCG
preferred.
- Must have excellent verbal and written communication and
ability to interact with diverse populations.
- Must have critical and analytical thinking skills.
- Must have demonstrated clinical competency.
- Must have the ability to Multitask and to function in a
stressful and fast-paced environment.
- Must have working knowledge of discharge planning, utilization
management, case management, performance improvement, and managed
care reimbursement.
- Must have an understanding of pre-acute and post-acute levels
of care and community resources.
- Must have the ability to work independently and exercise sound
judgment in interactions with physicians, payors, patients, and
their families.
- Must have an understanding of internal and external resources
and knowledge of available community resources.
- Other duties as assigned.
Job Requirements:
- Education/Skills
- Graduate of an accredited School of Nursing OR demonstrated
success in the Utilization Management Nurse I role for at least
five years at CHRISTUS Health on top of required experience in lieu
of education required.
- Experience
- Two or more years of clinical experience with at least one year
in the acute care setting OR demonstrated success as Utilization
Management Nurse I role at CHRISTUS Health required.
- Licenses, Registrations, or Certifications
- RN License in state of employment or compact required.
- LPN or LVN license accepted for associates with 5+ years of
demonstrated success and experience in the Utilization Management
Nurse I role at CHRISTUS Health.
- Certification in Case Management preferred.
- BLS preferred.
Work Schedule:
8AM - 5PM Monday-Friday
Work Type:
Full Time
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please contact us at (844) 257-6925.
Keywords: Christus Health, Tyler , Utilization Management Nurse II - Case Management, Healthcare , Tyler, Texas
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