DESCRIPTION OF POSITION

UR Case Manager (including ED) : Ensures that quality clinical services and financial outcomes are achieved within established time frames for assigned patients.

Coordinates the plan of care with the physicians, nurses and other health care professionals from admission through the discharge of the patient.

Facilitates judicious use of hospital resources. Monitors physician clinical documentation for content and completeness to assure it accurately reflects and substantiates the patient's diagnosis and procedures.

Performs duties in accordance with the Utilization Review Plan. Demonstrates thorough knowledge of performance measure requirements and reviews relevant charts for compliance.

Responsible for an initial medical necessity review for potential admitted patients and transition planning. Initial medical necessity reviews are critical to help determine the appropriate initial placement for patients.

The ED Case Manager will use an approved screening tool (Interqual or MCG) to help assess the appropriate admission status (inpatient or observation) in order to reduce future changes to status and level of care needed post-ED (.

acute, intermediate, critical). Collaborates with ED provider for clinical impression and provides them with the information needed to discuss expected treatment period, appropriate admission status and level of care.

Collaborates with ED providers and staff to create patients’ discharge plans including setting up equipment, medications, home health referrals, hospice consults and post-acute facility transfers.

Manage high-utilizer patients by addressing psychosocial causes, coordinating primary care, addressing insurance issues, and transportation.

Role includes accessing medical records to perform ongoing performance improvement audits.

QUALIFICATIONS

Professional / Educational Bachelor's degree required in a healthcare related field. Case management certification preferred (.

CCM, ACM). Minimum of 5-7 years clinical experience in acute hospital setting. Strong clinical expertise. Prior experience in utilization management or case management preferred.

Ability to maintain proficiency in the use of hospital information systems (., McKesson, Microsoft Word / Excel, Meditech, Midas, to enter and access information and record data.

General knowledge of state and federal regulatory requirements and payer / reimbursement methodologies. Licensure as Registered Nurse in Illinois.

• Personal Ability to communicate effectively in English, both verbally and in writing. Excellent negotiation skills with physicians and others to ensure patient receive appropriate and timely care.
• Work requires excellent interpersonal skills and the ability to maintain composure in difficult situations. Able to do manage multiple tasks in an organized manner;

high degree of flexibility required. Self -directed learner; enthusiastically seeks ways to improve patient care and motivate others to participate in improvement activities.

Possesses leadership skills and knowledge of hospital operations. Possesses advanced conflict resolution skills. Ability to work independently and be self-directing.

Last updated : 2024-04-28