Job Description

JOB SUMMARY

The Case Management team shall operate in an effort to deliver the most efficient, effective allocation of health care resources, while maintaining the maximal quality of services provided.

The evidenced-based clinical decision support criteria will be used for the evaluation of medical necessity with relation to admission and continued stay.

The Utilization Review (UR)case manager (CM) has well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. This individual monitors the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed. This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis. This individual leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff. The UR CM effectively and efficiently manages a diverse workload in a fast-paced, rapidly-changing regulatory environment. The UR CM is a member of and provides support to the hospital’s UR Committee. He/she collaborates with multiple leaders at various levels for the purpose of supporting and improving the UM program.

POSITION DIMENSIONS

Reports directly to

Team Lead, Case Management

Reports indirectly to

Case Management Manager

Financial Accountability

Support in secondary denial reviews

ROLE INTERACTS DIRECTLY WITH

TITLE/DEPARTMENT

FREQUENCY

TYPE OF INTERACTION

RN Case Manager

Daily

Patient care plan

Physician advisor/ physicians

As needed

Medical necessity / care plan

Finance

As needed

Operational need

Nursing and allied health

As needed

Patient care plan

KEY DECISIONS THE ROLE MAKES AND THE EXTENT OF THE IMPACT OF THE DECISION

Medical necessity and right level of care

PRIMARY JOB DUTIES AND RESPONSIBILITIES

1. Utilization Review Case Manager shall conduct admission and concurrent reviews on every admitted patient according to evidence-based criteria, contractual agreements required by payors.
2. Utilization Review Case Manager shall conduct evidence-based admission review based on appropriateness and medical necessity of admissions, assurance that patient placed in correct level of care.
3. Utilization Review Case Manager shall conduct Initial Review IR for all admitted patients through ED, clinics, transfer center, elective admissions, direct admission, and PACU.
4. Utilization Review Case Manager shall notify the unit CM if patient does not meet admission criteria and include unit CM in communication with physician advisor.
5. Utilization Review Case Manager shall document avoidable days when identified.
6. Utilization Review Case Manager shall conduct secondary review on the second day of admission for those who did not meet admission criteria
7. Utilization Review Case Manager shall do initial reviews when there is a change in level of care to a higher level.
8. Provide clinical consultation regarding UM to physicians and other colleagues .
9. Provide ongoing education to inpatient case managers, ED case managers, and other colleagues related to UM, medical necessity, patient status, non-coverage notifications, and other areas as requested.
10. Participate in the orientation of new caregivers in CM department.
11. Develop and provide individualized UM-related education as needed.

Communication

1. Demonstrates positive and professional written, verbal and nonverbal communication skills.
2. Utilizes negotiation skills, which effectively promote constructive solutions.
3. Applies advanced critical thinking and conflict resolution skills using creative approaches.

ROLE LEVEL ACCOUNTABILITIES

• Adheres to CCAD’s standards as they appear in the Code of Conduct and Conflict of Interest policies

In view of the evolving needs and opportunities within CCAD, this position may be required to perform other duties as assigned and reporting relationships may vary.

KEY OUTPUT / RESULTS FROM THE ROLE (KPI’S)

KEY PERFORMANCE INDICATOR

MEASURE

TARGET

As per departmental KPIs

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Typical physical demands include: a high degree of manual dexterity to sufficiently perform computer functions on a keyboard, produce materials on a PC and operate basic office equipment, normal or corrected vision and hearing, operate audiovisual equipment used during training programs, physically move, lift and carry training equipment and materials, mobility sufficient to visit with departments or employees throughout CCAD, stand in front of an audience for up to eight (8) hours a day and lift up to 30 lbs.

ORGANIZATION-WIDE COMPETENCY ASSESSMENT REQUIREMENTS

All employees will embrace the CCAD mission, vision and values and be responsible for adhering to the core values of the institution, including: Patient’s First, Collaboration, Mutual Respect, Quality, Patient Safety, Integrity, Cultural Sensitivity and Compassion.

All employees are also expected to meet the standards of performance outlined in the Organization-Wide Competencies listed below as applied to the position.

Customer Service Orientation includes attitude, behavior, interpersonal skill and problem solving that enable an employee to respond to internal and external customer needs and expectations in a positive manner. Adaptability including teamwork, flexibility needed to fulfill job responsibilities, adapting to changes in work environment and accepting supervisory feedback. Efficiency and Effectiveness includes quantity and quality of desired work, as well as organization skills necessary to perform successfully. Essential Job Requirements includes adherence to all relevant policies, procedures and guidelines affecting the work environment, as well as maintenance of required competencies and communication skills. Managerial Responsibilities includes overall accountability for assigned work group relative to operational goals, personnel requirements and budgetary constraints.

Assume responsibility of own safety and health and will abide by CCAD Occupational Health and Safety policies and procedures as per OSHAD and any other relevant requirements.

QUALIFICATION & EXPERIENCE REQUIREMENTS

ESSENTIAL

PREFERRED

Education

• Bachelors degree in Nursing
• Masters degree in Nursing (Preferred)

Experience

• Minimum of 5 years of nursing experience
• Minimum of 1 year in case management

Certification and Licensure

• RN DOH license

Professional Membership

• Utilization review certification
• CM certification

Job Specific Skills and Abilities

• Proficiency with Microsoft Office suite
• Fluency in written and spoken English