What are the responsibilities and job description for the Case Manager / Utilization Review Nurse position at Conway Regional Heath System?
Overview:
SAFETY SENSITIVE POSITION:
This position is a designated as “Safety Sensitive Position” under Act 593 of the State of Arkansas. An employee who is under the influence of Marijuana constitutes a threat to patients/customers which Conway Regional is responsible for in providing and supporting the delivery health care related services.
Qualifications:
Responsibilities:
Provides discharge planning and utilization review services in compliance with patient’s discharge planning needs and the hospital’s utilization review program.
SAFETY SENSITIVE POSITION:
This position is a designated as “Safety Sensitive Position” under Act 593 of the State of Arkansas. An employee who is under the influence of Marijuana constitutes a threat to patients/customers which Conway Regional is responsible for in providing and supporting the delivery health care related services.
Qualifications:
- Registered Nurse or Licensed Practical Nurse with current, active license to practice in Arkansas, required
- Proof of the highest level of nursing education achieved, required
- At least one-year experience in the area of case management/utilization review, preferred
Responsibilities:
- Demonstrates initiative and pursues activities which contribute to the accomplishment of goals and objectives
- Appropriately utilizes organizational resources to achieve the goals and objectives
- Considers cost implications in all decision making
- Promotes efficiency enhancements; actively identifies and implements cost savings/containment initiatives
- Apply clinical knowledge to determine appropriate acuity levels and utilization through chart review
- Effectively organizes workflow to consistently complete assignments in a timely manner
- Demonstrates ability to access and effectively utilize primary sources of data
- Obtains and maintains medical records in conformance with Medical Information policies
- Communicates with co-workers in a manner that is conducive to positive and effective working relationships. Demonstrates respect, honesty and integrity when working with other service providers
- Demonstrates compliance with all relevant hospital, state and federal requirements related to maintenance of confidentiality of persons, data and information systems
- Takes advantage of opportunities made available through CRHS and other professional organizations for continued professional growth and development
- Responsible for analysis of patient information for determination of necessity of admission or continuation of stay
- Review for medical necessity of admission on the first working day after admission using approved review criteria
- Reviews inpatient procedures to determine appropriate utilization and acuity level. Reviews potential for outpatient setting or swing bed utilization
- Reviews all patients for medical necessity of continued stay, or before the next review date, using approved review criteria
- Performs retroactive reviews, as necessary, and responds to the appropriate review agency or third-party payor
- Researches denials issued by review agencies and third-party payors and responds within the specified time frames for appeal
- Works with others on healthcare team to coordinate for patients discharge needs
- Establishes an effective utilization review process and maintains an active, effective utilization review file system. Recommends, develops and revises policies related to the utilization review process
- Works collaboratively with physicians, Case Management, the discharge planning process, Admissions, Central Scheduling and other CRHS associates
- Educates staff, physicians and other personnel regarding medical necessity requirements as defined by approved review criteria
- Attends 75% of staff meetings
- Participates in committees which promote staff and medical center facility growth as directed by Director/Manager and/or CRMC policy
- Attends mandatory in-services and committee meetings as assigned
- Adheres to dress code, conduct and attendance policies
- Participate in activities that promote personal development
- Must maintain all organizational education and work requirements (i.e., Annual Mandatory Education, Competencies, BLS Provider, etc.)
- Other duties as assigned by management