Concurrent Review Nurse Utilization Management Case Management Ful

Saturday, 14 October, 2017  10:27
SAN DIEGO, Tennessee

Description

Concurrent Review Nurse Utilization Management Case Management Ful - Description: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 members 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 reimbursementResponsible 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 ManagementAccountability 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 wiSalary:CompetitiveContract:PermanentCompany:CHI Memorial

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