Utilization Management RN

Job Summary

The Care Management Coordinator primary responsibility is to evaluate a member’s clinical condition through the review of medical records (including medical history and treatment records) to determine the medical necessity for patient’s services based on advanced knowledge and independent analysis of those medical records and application of appropriate medical necessity criteria. If necessary, the Care Management Coordinator directly interact with providers to obtain additional clinical information. The Care Management Coordinator has the authority to commit the company financially by independently authorizing services determined to be medically necessary based on their personal review. For those cases that do not meet established criteria, the Care Management Coordinator provides relevant information regarding members medical condition to the Medical Director for their further review and evaluation. The Care Management Coordinator has the authority to approve but cannot deny the care for patients. The Care Management Coordinator is also responsible for maintaining regulatory compliance with federal, state and accreditation regulations. Additionally, the Care Management Coordinator acts a patient advocate and a resource for members when accessing and navigating the health care system.

Key Responsibilities

Applies critical thinking and judgement skills based on advanced medical knowledge to cases utilizing specified resources and guidelines to make case determination. Utilizes resources such as; InterQual, Care Management Policy, Medical Policy and Electronic Desk References to determine the medical appropriateness of the proposed plan.

Utilizes the medical criteria of InterQual and/or Medical Policy to establish the need for inpatient, continued stay and length of stay, procedures and ancillary services.

Contacts servicing providers regarding treatment plans/plan of care and clarifies medical need for services.

Reviews treatment plans/plan of care with provider for requested services/procedures, inpatient admissions or continued stay, clarifying medical information with provider if needed.

Identifies and refers cases in which the plan of care/services are not meeting established criteria to the Medical Director for further evaluation determination.

Performs early identification of members to evaluate discharge planning needs.

Collaborates with case management staff or physician to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting.

Reports potential utilization issues or trends to designated manager and recommendations for improvement.

Appropriately refers cases to the Quality Management Department and/or Care Management and Coordination Manager when indicated to include delays in care.

Appropriately refers cases to Case and Disease Management.

Ensures request is covered within the member’s benefit plan.

Ensures utilization decisions are compliant with state, federal and accreditation regulations.

Meets or exceeds regulatory turnaround time and departmental productivity goals when processing referral/authorization requests.

Ensures that all key functions are documented via Care Management and Coordination Policy.

Maintains the integrity of the system information by timely, accurate data entry.

Qualifications:

Must have an active PA license or a Nurse Licensure Compact to include PA.

BSN Preferred

Minimum of three (3) years of Medical/Surgical experience.  

Previous Hospital Utilization Management (job title)

InterQual experience

Candidate must reside in the tri-state area (PA, DE, NJ)

Proficiency utilizing Microsoft Word, Outlook, Excel, SharePoint, and Adobe programs.

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