Concurrent Review Nurse - Utilization Management (Care Management) PRN - 8\:00a-4\:30p, Rotating Weekends (P000019189) - Full-time / Part-time

JOB SUMMARY\:  

Works collaboratively with physicians, staff and other health care professionals within his/her Division to review and monitor members’ utilization of health care services with the goal of maintaining high quality cost effective care. The role includes providing the medical and utilization expertise necessary to evaluate the appropriateness and efficiency of medical services and procedures. This includes providing referral authorization, concurrent review, proactive discharge/transition planning, appropriate referral to case management, and high dollar claims review. The Concurrent Review Nurse - Utilization Management is an integral member of the health care team as well as the Divisional Care Management team. Collaborates with the Divisional Care Management team on system-wide quality improvement/performance improvement initiatives. 

ESSENTIAL FUNCTIONS\:

• Performs initial, concurrent and retrospective reviews on all inpatient, facility and appropriate home health services.

• Ensures appropriate placement and monitors level and quality of care.

• Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.

• In conjunction with, and under the supervision of physicians, evaluates and provides feed-back to treating physicians regarding a member's discharge plans and available covered services including identifying alternative levels of care that may be covered.

• Presents facility-patient status updates and addresses barriers to discharge/transition at regularly held concurrent review rounds.

• Monitors all utilization reports to assure compliance with reporting and turnaround times.

• Addresses care issues with Director of Care Management, Physician Advisor and Chief Medical Officer/Medical Director as appropriate.

• Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for members.

• Coordinates identification and reporting of potential high dollar/utilization cases to reinsurer and finance department for appropriate reserve allocation.

• Consults with physicians, health care providers and outside agencies regarding continued care/treatment or hospitalization.

• Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum.

• Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies.

• Review per diem patients daily for medical necessity to ensure reimbursement

• Responsible for the early identification and assessment of members for potential inclusion in a comprehensive case management program. Refers members for case Management accordingly.

• Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities.

• Reviews any service denials and gathers necessary supporting documentation from chart audits and follows up according to procedures.

• Prepares CMS compliant notification letters of NON-certified and negotiated days within the established time frames.  Reviews all NON-certification files for correct documentation.

• Assists in the identification and reporting of Potential Quality of Care concerns.

• Responsible for assuring these issues are reported to the Quality Improvement Department.

• Provides backup for Case Manager.

• Work as an interdisciplinary team member within Divisional Care Management departments.

• Other duties as assigned within Population Health Care Management

Accountability for results\:

• Understands and self-manages to support facility/CIN-level success goals, including improvements in quality, cost of care and member experience for the facility/CIN’s population.

• Identifies opportunities for improvement (at individual, clinic and facility/CIN levels) and actively works with healthcare and facility/CIN team to correct or improve results.

Education\:

• Bachelor of Science in Nursing required; Masters of Science in Nursing preferred. Will accept equivalent experience in lieu of degree if the candidate obtains his/her BSN within 3 years post hire.

Experience\:

• Minimum 3 years clinical experience as Registered Nurse (RN) required.

• Minimum 5 years utilization management experience preferred.

• Demonstrated experience in utilization management, facility concurrent review, discharge planning, and transfer coordination.

• Experience with Indicia (formally Milliman Care Guidelines) authorization criteria preferred.

• Must have excellent computer skills and ability to learn new systems.

• Must have strong organizational (time management) skills, strong interpersonal skills,   the ability to handle multiple priorities with strong attention to detail  

• Knowledge of and practical use of good business English, spelling, arithmetic, practices and the ability to communicate effectively using written and verbal skills. Proficient in email communications and internet usage along with basic use of Microsoft Excel and Word.

• Knowledge of information technology to evaluate care effectiveness (care process, outcomes and cost)

• Ability to work autonomously within matrix environment without direct supervision or support.

License/Certification\:

• Current unrestricted license, as a registered nurse, in state(s) of practice is required.

• American Heart Association (AHA) Basic Life Support (BLS) for the Healthcare Provider certified or obtained by the end of the orientation period (approximately six (6) weeks).

• Proof of completion of Mandatory Reporter abuse training specific to population served within three (3) months of hire.

Additional Responsibilities\:

• Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.
• Adheres to and exhibits our core values\:
  Reverence\: Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.
  Integrity\: Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.
  Compassion\: Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.
  Excellence\: Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.
• Maintains confidentiality and protects sensitive data at all times.
• Adheres to organizational and department specific safety standards and guidelines.
• Works collaboratively and supports efforts of team members.
• Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.

Catholic Health Initiatives and its organizations are Equal Opportunity Employers. CBCHI

NOTICE

This position requires a criminal background check. Therefore, you may be required to provide information about your criminal history in order to be considered for this position.