Case Manager / Utilization Review Nurse

Job description

Overview
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.
Responsibilities
• 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.
• Assists with other department functions as assigned.

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