What are the responsibilities and job description for the Case/Utilization Review Manager position at Loretto Hospital?
Case/Utilization Review Manager
A Utilization Review/Case Manager r is responsible for ensuring that services provided are medically necessary and provided at the appropriate and least costly level of care.
Duties & Responsibilities
Provides utilization management functions for patients: pre-certification (primarily a function of the Admissions Department), Continued stay reviews and retro-reviews.
Assist physicians with determining correct level of care (CLOC) and medical necessity. Facilitates appropriate clinical level of care determination and conversions if necessary.
Responsible for notification to the Admissions Department of CLOC conversions.
Monitors internal and external UR guidelines for patients in assigned units or departments. Communicates key UM information to units and attending physician or their representative and managed care companies.
Applies approved utilization acuity criteria to monitor appropriateness of CLOC and continued stays and documents finding based on department standards.
Inputs and maintains utilization management data into computer system.
Participates in gathering and reporting data, such as variances, LOS, cost and outcomes.
Perform other related duties and participate in special projects as assigned.
Review medical data obtained by mail or fax and enter into the clinical record for review by the utilization review specialist.
Review and determine certification decision for all precertification cases forwarded to her by the utilization review specialist.
Discuss all cases lacking clinical information to allow certification with her supervisor prior to sending to the appropriate Physician Advisor for review. Follow up to assure PA response timely within Loretto guidelines.
Obtain discharge dates and bill totals for the Medical Review Specialist at the time of discharge to expedite closure of cases
Assist with projects as directed by the Director of Case and Utilization Management.
Participate in the Quality Management Program by adhering to all company policies and procedures and identifying opportunities for improvement to ensure quality services are rendered to clients and customers.
Minimum Qualifications
1. Graduation from an accredited professional nursing program
2. Current licensure as an LPN with the Illinois Department of Financial and Professional Regulation, Division of Professional Regulation
3. 2 to 4 years of utilization review & utilization management experience.
5. Current AHA BLS/CPR and other required unit specific certifications
6. Effective communication skills (oral and written) that facilitate therapeutic relationships between patients, family, and health care providers
7. Intermediate computer skills with the ability to become proficient in the Electronic Health Record (EHR) with on-the-job training
8. Excellent attendance, interpersonal skills and work history required.
