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Utilization Review RN Care Manager
Utilization Review RN Care Manager
Manages assigned caseload of high risk patients by working with the patient and family to develop a discharge plan utilizing identified needs, medical necessity criteria, and payor and/or managed care principals including hospital discharge planning as needed.
Collaborates with physician and interdisciplinary team to develop an optimal plan for treatment that meets the medical, psychosocial and financial needs of the individual. Reassesses and modifies the discharge plan as necessary.
Advocates to assist and support the patient and family through the continuum of care by communicating with the interdisciplinary team and including the health plan where appropriate.
Utilizes knowledge of community resources, payor requirements, Medicare, Medi-Cal and other contractual requirements.
Maintains a professional appearance at all times. Observes the QVMC and departmental dress codes, wears an ID badge and optional professional white lab coat.
Actively participates in organizational decision making groups such as nursing committees, councils, or task force teams (for example - shared governance and/or core councils) as requested.
Together with the patient, family/caregiver, and in collaboration with the social worker, coordinates and establishes goals to be accomplished to meet identified needs. Implements solutions and evaluates patient outcomes toward goals and revises plan as indicated.
Completes an initial discharge planning assessment in the electronic medical record on all patients that meet the departmental high risk indicators.
Maintains competency in current utilization review software. Conducts utilization review utilizing Milliman Care Web QI effectively to support admission status, determine length of stay and to assist with facilitation of the discharge plan.
Maintains competency in current case management software. Completes referrals, utilizes electronic faxing and readmission documentation. Ensures payor authorization documentation, as needed, for extended stays and completes avoidable day documentation.
Documents utilization management reviews according to Utilization Management Guidelines including admission/concurrent and retrospective reviews for commercial and government payors.
Exceptional communication and interpersonal skills.
Competent nursing assessment skills.
Sensitivity to the needs and situations of a multi-cultural population from a variety of income levels.
Strong organizational skills and ability to effectively present written and verbal information.
Proficiency with computers and telecommunication devices, such as smart phones.
Application of safety principles when performing duties.
Demonstrates ability to maintain fiscal responsibility in service utilization.
Ability to perform duties and responsibilities in an independent manner with little direct supervision, and complete job duties and responsibilities in a timely, accurate, thorough manner.
Models professionalism through effective time management, efficiency and a positive team approach.
Flexibility and an ability to adapt to changing and evolving hospital and departmental priorities.
Preferred: Bilingual (English/Spanish).
Current California RN license.
Current California Driver's License.
Preferred Position Qualifications:
Education: Bachelor's Degree in Nursing
Experience: Case management, discharge planning, or utilization management experience in the acute, sub-acute, home health setting or managed care environment
Licenses/Certifications: CCM or ACM Case Management certification.