Under the direction of the Quality Services Director and following Conditions of Participation CFR 440.168, 440.169, 482.30, and 482.43 provides hospital case management/utilization review and discharge planning to assure that the patient progresses through the continuum of care and is discharged to the least restrictive environment. Confers with physician’s to confirm appropriateness of patient’s admission and continued stay in health care environment. Ensure medical necessity is met and provided in the most appropriate setting. To ensure patients have appropriate access to care and resources. Promotes quality, safe and cost effective care. Promote appropriate utilization of available resources to achieve financial and clinical outcomes.
The position of Case Manager/Utilization Review is identified as “department safety-sensitive”.
Department safety-sensitive positions mean employment positions which may in the normal course of business:
- Require the employee to operate the company vehicles or heavy equipment, or
- Involves duties which, if performed with inattentiveness, errs in judgment, or diminished coordination, dexterity, or composure, may result in mistakes that could present a real and/or imminent threat to the personal health and safety of the employee, co-worker, and/or the public.
Delegation of Authority:
As the Case Manager/Utilization Review, you are delegated the administrative authority, responsibility and accountability necessary for carrying out your assigned duties.
Duties and Responsibilities:
1. Coordinates daily interdisciplinary patient care utilization management meeting.
2. Screens cases for appropriate admission/readmission/observation status.
3. Conducts review for appropriate utilization of services from admission through discharge. Ensure services are medically necessary and reasonable.
4. Is knowledgeable and proficient in use of MCG (Milliman Care Guidelines) and documents daily entries using utilization review tool for each patient.
5. Confers with physician to confirm appropriateness of patient’s admission and continued stay in the health care environment.
6. Performs concurrent chart reviews in order to actively manage resources and assure supporting documentation adequately reflects patient severity and monitor for physician quality services.
7. Length of stay review (ensure transition to the next level of care as quickly as possible once the patient no longer meets clinical criteria for the current level of care).
8. Performs monthly audit on inappropriate admission types and inappropriate inpatient days per MCG guidelines with breakdown per MD.
9. Denial management; monitoring and managing 3rd party payor reimbursement in collaboration with patient access department.
10. Initiate referrals to the appropriate areas to expedite care, treatment and services in consultation with clinical staff.
11. Responsible for the arrangement of care and interventions that the patient will require during hospital stay and upon discharge.
12. Discharge planning; facilities timely discharge and document plans.
13. Collaborates with social worker in discharge planning for complex patient discharge to long term care placement.
14. Collaborates with patient, family and clinical staff in the development of execution of the discharge plan of care.
15. Completes PASRR assessments as needed for long term care and swing placement.
16. Maintains current knowledge of practice and skills regarding case management principles through education, literature review, and presentations.
17. Performs quality assurance for case management program.
18. Quality Management; review and reporting of any patient readmitted within a 30 day period of time (MCG guidelines).
19. Communicates with the physicians at regular intervals throughout the hospitalization and develops an effective working relationship.
20. Provides concurrent review of patients meeting criteria and reports deficiencies to the appropriate care provider.
21. Provides education to hospital staff and physicians regarding core measure requirements Via formal and informal presentations.
22. Participate and educates in clinical documentation improvement as requested.
23. Performs and documents discharge follow-up calls for all acute and swing patients discharged to home
24. Maintains written policies and procedures for case management, utilization review, and discharge planning.
25. Reviews swing bed admissions for completion of required regulatory documentation
25. Maintains confidentiality of all patient/resident/staff information.
26. Performs additional assignments as requested
Combination of related experience and/or education. Bachelor’s degree in a healthcare related field required (or actively pursuing upon hire). Two years of experience in case management or utilization review in an acute setting or related healthcare experience preferred. Minimum of 1 year experience in discharge planning if preferred. Must be able to function independently. Must be able to function effectively under stress.
- Demonstrates knowledge of healthcare regulations, such as Conditions of Participation from Medicare and CMS as related to case management, utilization review, and discharge planning.
- Demonstrates the knowledge and understanding of intensity of service, severity of illness, and opportunities for intervention, planned course of treatment/procedures, care needs, and outcome goals.
- Demonstrates an understanding of the role of payers and providers, the need for cost containment and the effect of appropriate resource utilization.
- Requires a strong working knowledge of multidisciplinary care planning, community agencies, services/resources available to assist the patient and family in problem solving resolution of emotional, social and financial issues relating to hospitalization and needs.
CPR/AED certification required
Nevada Registered Nurse license
Required Protective Equipment:
Gown, medical gloves, face shield as necessary and other equipment as required by OSHA regulations and hospital policy.
Able to read, write and speak the English language in an understandable manner
Ability to manage multiple projects
Willingness to work harmoniously with professional and non-professional personnel
Effective Communication skills
Computer, typing and composition skills
One to two year UR experience preferred
Sufficient experience as a staff nurse in general nursing
Knowledge of DRG, ICD-9/ICD-10 coding; working knowledge of MCG Health/CareWebQI and Medicare regulations
Thorough knowledge of State of Nevada Bureau of Licensure quality improvement requirements
Ability to make independent decisions
Physical Requirements: The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of the job.
Light to moderate physical effort (lift/carry/push/pull up to 25 lbs)
Occasional prolonged standing/walking
Manual dexterity and mobility
Visual acuity with or without correction
Working conditions: The above statements are intended to describe the general nature and level of work typically performed by an employee on this position. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified.
May be exposed to infections and contagious diseases
Occasionally exposed to the risk of blood borne disease
Occasional exposure to unpleasant elements (accidents, injuries and illness)
Subject to varying and unpredictable situation