The RN Case Manager/Utilization Review Nurse will act as a patient advocate by investigating all adverse occurrences. Perform staff education related to utilization of resources, discharge planning, and the psycho-social aspects of healthcare delivery. Determine the medical necessity for all admissions and need for continued stay, as well as status the patient in the correct level of care, and document accordingly.
• Clinical liaison between hospital, clinical and administrative staff.
• Manages assigned case load in an efficient and effective manner to facilitate the total work process.
• Interact and collaborate with the interdisciplinary care team: Physicians, Case Managers, and Health Service/ UM Coordinators
• Coordinate timely, appropriate discharges from the hospital, and identify opportunities for improvements in patient care.
• Provides expertise in clinical authorizations for inpatient care and/or alternate level of care based on utilized evidenced-based criteria, and effective communication with Physicians and Physician Advisers on a regular basis.
• Provides assessments of physical, psycho-social and transitional needs in settings not limited to the PCP office, hospital, or member’s home.
• Negotiates level of care, intensity and duration of services as appropriate.
• Maintains knowledge of health plan benefits and provider network contract language.
• Guides physicians in their awareness of preferred contracts, providers and facilities.
• Enters timely and accurate data into designated care management applications to communicate patient needs
• Delivers health management training to patients and their families to meet short and long-term care plan goals.
• Facilitates care coordination through departmental utilization rounds.
• Plans member transitions with providers, patient and family.
• Problem solving and individual reasoning skills. Gather and/or review facts and select the best solution from identified alternatives, writing procedures as necessary.
• Takes on-call assignment as directed
• Performs all other related duties as assigned.
• Competitive annual salary
• Full benefit package available