Utilization Review Case Manager role at Waterbury Hospital
Scope of Position
The Utilization Review Case Manager (UR CM) works in collaboration with the physician and interdisciplinary team to support the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. The role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care, promoting clinical best practice, and ensuring all patients receive the right care, at the right time, and in the right setting. The UR CM is responsible for preoperative, concurrent, and retrospective reviews in accordance with the utilization management plan. The UM CM ensures the appropriate status and level of care is determined and ensures accurate assessment of medical necessity, thus appropriate reimbursement. Performs duties in support of the ECHN mission to ensure the highest quality of patient care in an economically sound and efficient manner.
Responsibilities
Conduct concurrent and retrospective reviews utilizing InterQual, Milliman Care Guidelines, or CMS rules and regulations for medical necessity criteria to monitor appropriateness of admissions and continued stays, and document findings based on department policy/procedure; refer appropriate cases to Physician Advisor for recommendation(s).
Ensure order in chart/EMR and status coincides with the IQ or MCG review or CMS rules for appropriate Level of Care and status on all patients through collaboration with Case Manager.
Demonstrate thorough knowledge in the application of medical necessity criteria.
Assess the safest and most efficient care level based on severity of illness, comorbidities and complications, and the intensity of services being delivered.
Utilize appropriate payer criteria to provide recommendation(s) to the attending physician.
Communicate payer criteria and issues on a case-by-case basis with multidisciplinary team and follow up to resolve problems with payors as needed; initiate peer-to-peer when appropriate.
Contact the attending physician for additional information if the patient does not meet the appropriate medical necessity criteria or in accordance with CMS rules and regulations for continued stay.
Escalate reviews timely to Physician Advisor for lack of medical necessity and/or status discrepancies.
Educate physicians and interdisciplinary team regarding approved criteria practice guidelines, level of care, length of stay, and alternative treatment options.
Support multi-disciplinary strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes.
Collaborate with multidisciplinary team members to identify and implement strategies to ensure appropriate utilization and achieve positive patient outcomes.
Demonstrate knowledge of target length of stay and GMLOS for diagnosis by actively monitoring length of stay timeframe and implementing measures to achieve targets.
Prevent denials by providing timely clinical reviews to payers for authorization of services provided and complete case review for claim reimbursement.
Review outlier cases to determine level of care and clinical appropriateness.
Assist as appropriate in the collection and reporting of financial indicators including length of stay, approved, denied, and avoidable days, and resource utilization.
Demonstrate skill in communicating with physicians the necessary documentation to demonstrate medical necessity.
Utilize data to drive decisions related to utilization management for assigned patients, including fiscal and clinical data.
Be responsible for yearly re-education on industry standard criteria, i.e., InterQual/Milliman Care Guidelines.
Collect and analyze data to provide information regarding system barriers to care delivery, patient care outcomes, resource trends and patterns.
Advocate for, support, and protect the rights of patients. Promptly report any potential compromise of rights to appropriate individuals.
Identify quality, infection control, utilization, and risk management issues with referrals to appropriate committee or personnel.
Continuously pursue excellence in meeting the needs and expectations of all customers (patients, families, inter-disciplinary team members, payors, screeners, liaisons and outside services and agencies).
Perform all other duties as assigned.
Requirements
Bachelor’s Degree in Nursing or a related field.
Current licensure as an RN.
2–3 years of experience in case management, discharge planning, and/or progression of care in the acute‑care setting.
Must have a strong understanding of medical disease processes and clinical background.
Minimum of 1 year Utilization Review experience preferred via industry clinical standards, i.e., InterQual, Milliman Care Guidelines.
Competencies
Comprehensive knowledge of the health care reimbursement system.
Demonstrated skill in creative problem solving, facilitation, collaboration, coordination, and critical thinking.
Excellent oral, written, and communication skills.
Proficiency in the use of work processing and spreadsheet application.
Working knowledge of healthcare reimbursement and available community resources.
Must have strong computer skills and the ability to access internet and other programs applicable to Waterbury Hospital procedures.
Perform automated functions that fall within job responsibility.