Under general supervision, performs review of patient charts as required by the Hospitals Utilization Management Review Plan.
The Utilization Review Case Manager (UR CM) validates the patient's placement to be at the most appropriate level of care based on nationally accepted admission criteria.
The UR CM uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial (if not complete) and continued stay reviews in determining appropriate levels of patient care.
The UR CM secures authorization for the patient's clinical services through collaboration and communication with the payers as required.
The UR CM follows the UR process as defined in the Utilization Review Plan in accordance with the CMS condition of Participation for Utilization Review.
Core Competencies Anticipates and assesses and informs payers of patient's discharge planning needs.
Assesses need for home durable equipment, follows-up with home health and include(s) anticipated need in communication with payers
Assists and supports a new or transferred employee through a planned orientation.
Assists with the orientation and competency assessment of staff.
Attends denial management committee.
Collaborates with interdisciplinary and communicates this plan to the payer
Collaborates with RN Case Managers and the Physician Advisors to facilitate the peer to peer process in order to mitigate potential denials
Collaborates/communicates with external case managers.
Communicates with the patient, family, medical staff and others during the continuum of care
Completes all documentation in a clear, clean, concise manner.
Complies with all applicable laws and regulations.
Complies with organizational quality dashboard/benchmarking goals
Complies with Joint Commission’s national patient safety goals
Demonstrates culturally competent patient care.
Demonstrates good customer relations skills.
Demonstrates independent judgment, autonomy, initiative, time management and organizational skills and the ability to prioritize projects/functions in a busy work environment.
Demonstrates knowledge of clinical norms for the different age groups as applicable to job functions.
Develops and maintains cooperative relationships with hospital personnel, physicians, suppliers and insurance case managers.
Demonstrates interpersonal communication skills that enable exchange of ideas and information effective with patients, families, and colleagues of all levels
