Case Management/Utilization Review Manager

This position has overall responsibility for operational management and performance improvement of Utilization Management to promote effective utilization of hospital resources, ensure processes support appropriate reimbursement for services rendered, support efficient patient throughput, facilitate quality of patient care, and ensure compliance with all state and federal regulations.

32-40 hours per week

QUALIFICATIONS

• Valid, current RN licensure in the State of Texas (required)

• Five years acute healthcare experience (required)

• Minimum of three years of experience with case management/utilization management, data management and reporting methodologies and clinical chart review/ abstraction (preferred)

• Robust knowledge of utilization management principles, Medicare, Medicaid, HMO and private insurance benefits/coverage guidelines/requirements (preferred)

• Bachelor’s degree in Nursing (preferred)

ROLE AND RESPONSIBILITIES

• Promote cooperation with utilization review standards by the medical staff   

• Facilitate communication between clinical, financial, patient access and leadership on a regular basis regarding utilization review and/or quality issues 

• Train/mentor house supervisors regarding proper admission status after hours/weekends

• Complete preadmission, admission and continued stay reviews as outlined by the Utilization Review Plan

• Facilitate and/or obtain appropriate physician documentation to support the appropriate severity of illness, expected risk of mortality, and complexity of patient care 

• Collaborate with discharge planning personnel, nursing staff, and other ancillary staff to facilitate quality of care/continuity of care  

• Monitor emergency department patients for disposition  and facilitate appropriate follow up

• Facilitate and improve transitions of care

• Partner with Swing Bed Coordinator to optimize swing bed program

• Complete nurse evaluation for swing bed referrals

• Follow up with transfers out of the facility for potential swing bed admission

• Partner with the Health Information Management staff to ensure accuracy of diagnostic and procedural data and completeness of supporting documentation 

• Lead the appeal process resulting from third-party reviews

• Follow established organizational policies for referral of variances for case review

• Collect and analyze data to identify patterns, trends and opportunities for improvement (i.e., length of stay, avoidable days, denials, readmissions, etc. and provides reports to the CNO and CQO monthly, and as needed or requested, and quarterly to the UM Committee (subcommittee of the Pharmacy and Therapeutics Committee)

• Propose, develop and implement process change based on identified needs identified through concurrent and retrospective review and aggregate data analysis 

• Evaluate Utilization Review Plan and other applicable documents annually, and as needed, and revise accordingly

• Educate and serve as a resource to the patient care team regarding best practice, quality measures/initiatives, clinical documentation requirements, reporting and reimbursement issues, etc.   

• Refer matters of potential conflict immediately to the attention of the executive leadership 

• Provide support for social worker and preauthorization personnel when out of the office

• Provide support for nursing directors when needed

• Complete discharge phone calls to patients within 2-3 days after discharge

REQUIREMENTS 

• Support CMH’s mission, vision, core values and customer service philosophy

• Adhere to the CMH Compliance Program

• Comply with all local, state and federal accreditation, statutory and regulatory standards, as well as all organizational policies    

• Maintain current clinical certification(s) and competencies required to support clinical staff

• Demonstrate outstanding customer service/advocacy, professionalism and integrity

• Perform other duties as assigned 

KNOWLEDGE, SKILLS AND ABILITIES

• Strong organizational and interpersonal skills including the ability to communicate effectively, both orally and in writing

• Strong reasoning/clinical decision making skills

• Excellent time management, collaboration, prioritization and problem-solving skills

• Proficiency with computer skills including Microsoft Office applications and EHRs

• Willingness to adapt to change and support new technologies as well as policies and procedures in a positive manner

PHYSICAL REQUIREMENTS AND ENVIRONMENTAL CONDITIONS

• At times may have to work irregular hours under physically demanding, high-stress environment

• Exposure to blood and body fluids, communicable diseases, chemicals, radiation, and repetitive motions

• Pushing and pulling heavy objects

• Full range of body motion including handling and lifting patients

• Position requires light to moderate work with 50 pounds maximum weight to lift and carry

• Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing