The Utilization Review/Case Manager will assure maximum coverage by third party payers for patients utilizing services; monitor patient records concurrently for necessary documentation and adherence to criteria. Facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and coding staff to ensure that clinical documentation reflects the level of service rendered to patients is complete and accurate.

BASIC FUNCTION: Concurrently and retrospectively reviews patient medical record utilizing specific medical care review criteria to assure proper utilization of hospital facilities and/or resources, and documentation in compliance with all rules and regulations as promulgated by third party payors, thus minimizing financial loss to the hospital and the patient. Contacts various insurance carriers to provide pertinent information on their beneficiaries. Identifies variances affecting utilization of hospital resources and quality of care and communicates those findings. Performs pre-certification, certification, and re-certification of patients charts associated with external review agencies. Compiles reports for the Quality Council and Medical Staff on current utilization review statistics and quality measures.

SHIFT DAYS/HOURS: 40 hours/week M-F Subject to change based on business necessity.

QUALIFICATIONS:

Education: Graduate of a state accredited school of nursing as an RN/LPN, or RHIT or equivalent position.

Experience: Experience applying customer service behaviors and communication skills required. Experience as a clinician in an acute care nursing unit or experience in a Health Information Management field with Utilization Review job duties necessary. At least two years experience with Utilization Review and Quality Assurance preferred.

Certificates, License, Registrations:

Knowledge, Skills and Abilities: Must be knowledgeable in disease and disease process, broad knowledge of pharmacology indications for drug usage and related adverse reactions; knowledge of ancillary testing (laboratory, X-ray, EKG), knowledge of anatomy, physiology and medical terminology. Must maintain a high level of professionalism with co-workers and Medical Staff. Must be able to demonstrate the ability to prioritize workload and manage time efficiently. Maintain compliance with HIPAA and patient confidentiality.

Physical: Light Work: Exerting up to 20 pounds occasionally, and/or 10 pounds of force frequently, or negligible constantly. Walking or standing to a significant degree, or sitting constantly and pushing/pulling controls.

Mental Health: Must possess good general mental health; ability to work under pressure; ability to communicate effectively in both written and verbal form. Must establish priorities among essential functions of the job and coordinate those functions with others; ability to speak, read and write the English language.

INTERPERSONAL RELATIONSHIPS:

Supervision Received: Director of Nursing

Supervision Exercised: None

Other: Patients, families, visitors, other hospital personnel, medical staff, other medical facility personnel, community program personnel, mortuary personnel, EMS personnel, members of the general public

EXPOSURE TO HAZARDS:

To reduce job hazards, this position is responsible for wearing PPE during job functions. PPE can include: gloves, gown/coat, shoe covers, head/face, eye and ear protection. Each job function requires a different level of PPE, individuals receive initial and annual training to identify the appropriate level of PPE required

According to OSHA standards, this position is classified as low risk with little or no risk of exposure, Class III

EQUIPMENT USED:

Electronic health record and associated software and equipment, personal computer, printer, scanner, photocopier, Microsoft Office applications and email. If a nurse holds this position, it may be necessary to use patient transfer equipment and patient care equipment and monitors, as needed.

GENERAL REQUIREMENTS :

The following requirements are expected of all employees:

Periodical Health Screening and Annual Influenza Vaccination

Core Values: Integrity, Compassion, Excellence, Service

Safety Awareness: Hospital Fire, Safety, and Disaster Procedures

Confidentiality: Maintains Employee and Patient Confidentiality

Attendance: Regular attendance is an essential function of the position

Character: Attitude, Integrity, Role Modeling

Job Performance: Results Orientation, Customer Focus, Decision Making, Awareness

Interpersonal Skills: Communication, Relationship-building, Team Player, Celebration

Innovation: Breakthrough Thinking, Knowledge-Building/Sharing, Coaching/Empowering, System Vision & Management

ESSENTIAL FUNCTIONS:

• To monitor adherence to the hospital's utilization review plan to ensure the effective and efficient use of hospital services. To monitor the appropriateness of hospital admissions and extended hospitals stays.
• Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to comply with government and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.
• Performs concurrent reviews for patients to ensure that extended stays are medically justified and are so documented in patient's medical records.
• Performs on-site and/or telephonic concurrent review of acute, Observation and Swingbed services, as well as precertification review for all services following the plans authorization guidelines.
• Reviews application for patient admission and approves admission or refers case to facility utilization review committee for review and course of action when case fails to meet admission standards.
• Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.
• Abstracts data from records and maintains statistics for internal reporting.
• Utilization Review/Quality Performance Improvement
• Abstracts data from records for federal, state reporting requirements CART (CMS Abstracting and Reporting Tool)
• Inpatient Measures
• Outpatient Measures
• PQRS/MIPS Reporting (Physician Quality Reporting System) (Merit-Based Incentive Payment System)
• QHi Reporting
• Kansas HEN Reporting
• Determines patient review dates according to established diagnostic criteria.
• May assist review committee in planning and holding federally mandated quality assurance reviews.
• Identifies problems related to the quality of patient care and refers such problems to the Quality Assurance Committee
• Maintains a liaison with the Social Service Department to facilitate timely discharge planning. Compiles monthly reports and statistics for presentation to the Utilization Review Committee.
• Participates in weekly multi-disciplinary team for Swing Bed discharge planning meetings.
• Manages Policies and Procedures in MCN
• Monthly New Employee Orientation for MCN Poly Manager
• Upload, review, revise and approve policies.
• Other duties as assigned.