SEH-UR/CASE MANAGER RN

General Purpose of Job:

Performs utilization review of patient records according to Interqual criteria to assess
utilization of services, quality of care, and continuing need for hospitalization to ensure optimum quality of care and reimbursement for services provided.

Essential Duties:

• Performs utilization review of patient records to assess utilization of services, quality of care, and continuing need for hospitalization to ensure optimum quality of care and reimbursement for services provided; notifies appropriate personnel of risk management and/or quality of care issues. Refers cases warranting medical review to Physician Advisor.
• Contacts insurance companies, as needed, to obtain pre-certification authorizations and clinical information; initiates correction of insurance and demographic information as needed.
• Provides education and information to physicians and hospital staff regarding case management/utilization review, third party reimbursements and ways to improve reimbursement.
• Monitors compliance with hospital policy, TJC requirements and other regulatory agencies.
• Will analyze CM worksheets and complete Core Options reports according to current guidelines and meet required deadlines.
• Communicates regularly with physicians, healthcare professionals, and others regarding patient's treatment, progress and discharge planning.
• Coordinates the discharge planning function including identification of the patient's discharge planning needs, assisting the patient/family in developing a plan, coordinating arrangements to meet the discharge planning needs, arranging for transfer to extended care facilities when indicated, and preparing written correspondence for external contacts as needed.
• Attends interdisciplinary care team meetings and maintains communication with other disciplines to facility quality patient care, resolve problems and exchange information. Train and educate on case management and core options.
• Develops and maintains working relationships with community agencies and services to promote interagency cooperation and facilitate related referrals.
• Attends staff meetings and in-service programs.
• Supports and serves as a role model for our mission, vision, values and customer services initiatives. Adheres to the organization's policies and procedures and compliance guidelines.
• Uses Code of Ethics for Nurses to guide professional practice.
• Performs other duties as assigned.