Utilization Management RN - FT Days

Number of Positions In Requisition 1

 Job Details Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Wil assist in discharge planning to other levels of care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.

Job Description Summary Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Wil assist in discharge planning to other levels of care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.

Job Duties Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson. Collaborates with the Physician Advisor and members of the Multidisciplinary Team to facilitate the Medical Necessity process. Applies approved utilization acuity criteria to establish appropriateness of admissions and patient status, and documents findings based on department standards. Applies initial DRG for all inpatient admissions and documents appropriately (excluding Jefferson New Jersey).

Minimum Qualifications Bachelor’s Degree Nursing, required 3 years case management experience, discharge planning or utilization management experience required. Knowledge of managed care, governmental and third party payers reimbursement. Must be proficient with InterQual and mcg criteria and its application. Strong interpersonal relationships. Ability to: prioritize workload; collaborate with others to meet multiple deadlines; communicate effectively orally and in writing; work in a team environment, document in electronic health records.

Knowledge of the medical, social, economic, and other services provided by other departments or facilities, and the ability to integrate these multidisciplinary treatments for optimal patient care. Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices. Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.

Ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation. Refers cases to the Physician Advisor or external Physician Advisor per department procedures which require further review or clarification. Applies specific relevant medical necessity criteria for all patients to determine the appropriate patient status.

Documents appropriate medical necessity criteria level of care guidelines subset. (InterQual) Follows departmental procedures for Condition 44 downgrades, including medical record documentation, and informing patient and Case Manager. Refers cases without documentation of acute level of care to the Physician Advisor. Adheres to organizational policies and procedures, identified third party payer contract utilization management workflows and governmental payer processes.

Complete a medical necessity review for observation status patients in the E.D. via Patient Status Board, at minimum of every 4 hours to determine if patient status has changed or patient can be discharged. Applies initial DRG for all inpatients and document in the Care Advance. Completes an initial assessment to assess patient’s needs and resources for discharge planning. Establishes discharge plan including homecare services, transportation, post-acute facility placements.

Refers appropriate patients to the E.D. Social Worker for intervention. Interface with appropriate Inpatient Case Manager to provide all necessary information. Case Management Safety Competencies: Identified patients usi