The Utilization Management RN is responsible for utilization management and inpatient care management coordination and will perform reviews of current inpatient services, and determine medical appropriateness of inpatient and outpatient services by following medical guidelines and benefit determination. They will also identify, screen, track, monitor and coordinate the care of members with multiple co-morbidities, psychosocial needs, transition needs and develop a nursing plan of care as well as prospective, concurrent, and retrospective utilization review of inpatient services. The Utilization Management RN acts as an advocate for members and their families by linking them to other members of the care team to help them gain knowledge of their disease process and to identify community resources for continued growth toward the maximum level of independence. The Utilization Management RN is responsible for the case management activities across the continuum of care including coordination of care, medical management consulting and may also provide health education, coaching and treatment decision support for members. The Utilization Management RN participates in interdisciplinary conferences and Patient Care Coordination Meeting (PCC) to review clinical assessments, update care plans and determine follow-up frequency with the team.
***This position is a telecommuter role but will need to attend meetings in office located in Phoenix. ***
The RN is also responsible for being onsite in the hospitals and telephonic.***
Primary Responsibilities:
1.Collaborates effectively with interdisciplinary team (IDT) to establish an individualized plan of care for members. The interdisciplinary care team Develops interventions to assist the member in meeting short and long term plan of care goals. Works with Transition of Care Coaches and Post-Acute Team to facilitate smooth care transitions.
2.Serves as the clinical liaison with hospital, clinical and administrative staff as well as provides expertise for clinical authorizations for inpatient care. based on utilized evidenced-based criteria
3.Assess and evaluate new admissions and determines appropriate level of care based on evidenced-based criteria as well as monitors daily in-patient census for accuracy.
4.Stratifies and/or validates patient level of risk and communicates during transition process with IDT
5.Provide assessments of physical, psycho-social and transition needs in settings not limited to the PCP office, hospital, or member's home. Develops interventions and processes to assist the Health Plan and/or MSO member in meeting short and long term plan of care goals.
6.Coordinates and attends member visits with PCP and specialists as needed.
7.Manages assigned case load in an efficient and effective manner utilizing time management skills to facilitate the total work process directly monitoring assigned members
a.Provides constructive information to minimize problems and increase customer satisfaction.
b.Seeks ways to improve job efficiency and makes appropriate suggestions following the appropriate chain of command.
8.Demonstrates knowledge of utilization management and care coordination processes and current standards of care as a foundation for transition planning activities.
9.Confers with physician advisors on a regular basis regarding inpatient cases and participates in departmental utilization rounds. Plans member transitions, with providers, patient and family.
10.Enters timely and accurate data into designated care management applications as needed to communicate patient needs and maintains audit scores of 90% or better on a quarterly basis.
11. Adheres to organizational and departmental policies and procedures and credentialed compliance.
a.Takes on-call assignment as directed.
b.Attends and Participates in interdisciplinary team meetings as directed
12.Problem solving by gathering and /or reviewing facts and selecting the best solution from identified alternatives. Decision-making is usually based on prior practice or policy, with some interpretation. Must apply individual reasoning to the solution of problems, devising or modifying processes and writing procedures as necessary.
a.Maintains current knowledge of health plan benefits and provider network including inclusions and exclusions in contract terms.
b.With the assistance of the Managed Care/UM teams, guides physicians in their awareness of preferred contracts and providers and facilities.
13.Participates in the development of appropriate QI processes, establishing and monitoring indicators.
14.Performs all other related duties as assigned.
Keywords:
RN
Utilization Management
Case Manager
Phoenix
Telecommute
On-site
Telephonic
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