RN Case Manager - Utilization Review

Requirements

• A current and unrestricted Arizona Registered Nurse (RN) license.
• Certification in Health Care Quality and Management (HCQM) or as a Certified Case Manager (CCM) credential preferred.

KNOWLEDGE • Medical Necessity Analysis

• This skill involves a detailed evaluation of patient medical records. The nurse must critically assess the documented clinical information to determine if the proposed treatments, procedures, and services are medically appropriate and necessary according to established standards.
• Payer-Provider
• Liaison: Acting as a crucial communication link, the nurse must effectively mediate between healthcare providers and insurance payers. This requires translating clinical information into the language of insurance requirements to resolve discrepancies and pre-emptively address potential denials.
• Utilization
• Data
• Interpretation: This involves collaborating with the Revenue Cycle Management (RCM) team to analyze utilization data to spot trends, such as patterns in claim denials, delays in care, or inefficient use of resources. This analysis helps inform process improvements and strategic reporting within the healthcare facility.

SKILLS • Patient Assessment

• Conduct comprehensive assessments of patients' medical, emotional, and social needs to develop individualized discharge plans that ensure continuity of care.
• Care
• Coordination: Collaborate with healthcare providers, including doctors, nurses, and therapists, to create an integrated plan of care that addresses clinical needs, equipment, home care, and other requirements.
• Discharge
• Planning: Determine the appropriate discharge disposition based on factors such as living situation, mobility, cognitive status, and available support systems. This includes deciding whether patients can return home with services or require care in a facility.
• Arranging
• Services: Coordinate necessary post-discharge services, such as home health care, rehabilitation, and durable medical equipment, ensuring that these services are in place before the patient leaves the hospital.
• Communication: Maintain clear communication with all parties involved in the patient's care, including insurance providers, to secure coverage for post-discharge services and ensure that receiving providers are informed of the patient's needs and changes in their condition.
• Clinical
• Guideline
• Application: Applying standardized clinical criteria, such as InterQual or MCG, is a core function. This involves interpreting complex medical information and using these evidence-based guidelines to objectively justify admission, continued stays, and the appropriate level of care.

• Abilities
• Ability to work in a high-stress, fast-paced environment.
• Ability to develop relationships with providers, staff, patients, families, and payors.
• Ability to work cooperatively and professionally in a team environment.