Utilization Case Manager RNApply
• Works in collaboration with the physicians, physician advisor, members of the healthcare team and payers to address all clinical/customer/payer issues in a timely manner.
• Conducts assessment and care planning.
• Reviews documentation and completes an initial Inpatient screen to all customers for admission (Inpatient-IP, OBSERVATION/Outpatient-OBS, OPIAB/OP) appropriateness, uses system approved criteria (InterQual-IQ or Milliman Care Guidelines-MCG) to identify needs related to clinical outcomes, complex care coordination, and transition/discharge planning.
• Documents approved/appropriate status in EPIC- as communication mechanism to Case Managers/Social Workers for ongoing care progression.
• If a case fails the screening criteria, contacts the physician to review the documentation, requests further information/documentation to assure appropriate status is achieved or maintained.
• Refers cases to peer-review when documentation does not support the status (specific screening) at time of admission.
• Communicates outcomes of peer review process to appropriate physician and documents in EPIC outcome.
• Reviews Observation cases daily to assess possible need for conversion in status.
• Reviews Inpatient cases as requested by payors/LOS parameters for discharge indications.
• Screens cases from an ongoing perspective as requested by external customers.
• When a clinical status changes, applies appropriate Condition Code (CC44- inpatient(IP) converted to OP/OBS or Occurrence Span code (OSC 72) OBS converted to IP) and documents in EPIC-claim info screen as well as note in customer progress notes.
• Communicates with Case Management/Social Services for status revision (may affect placement/coverage/customer satisfaction) so appropriate IMM/MOON may be issued.
• Documents status changes and how status change determinations were made in EPIC-Authorization/Certification Information account notes.
• Reviews EPIC Master Daily Schedule to assess for appropriateness of proposed surgical procedures.
• Reviews readmission chart to determine possible premature discharges.
• Reviews discharge chart to determine case/status completion.
• Reviews extended stay chart to assess for Medicare 20-day recertification documentation (medical necessity/ongoing appropriateness).
• Reviews outlier recertification.
• Provides clinical information to reflect that customers are placed in the appropriate level of care.
• Addresses any issues related to status and clinical appropriateness on a concurrent and retrospective basis.
• Maintains awareness of relevant payor requirements, restrictions and reimbursement methods.
• Communicates reimbursement information to physicians/social workers/customers and families as appropriate.
• Assists in the identification and communication of any issues related to infection control, risk management, quality of care, and customer medical management, by reporting variance cases to appropriate departments for follow up.
• Adheres to the organizational policies and standards as well as standards from external regulatory agencies and accrediting bodies (i.e., JCAHO, CMS, Department of Public Health, etc.).
• Serves as a reference and resource for business office, medical records, compliance, partnering clinics and health care systems.
• Bachelor’s Degree from an accredited school of nursing required.
• Three (3) to five years of previous acute care nursing experience required.
• One (1) year of direct case management experience required.
• Hospital case management and utilization management experience required.
Knowledge, Skills and Abilities
• Knowledge of nursing theory and practice and primary care principles and practices.
• Knowledge of Medicare rules and regulations.
• Knowledge of current case management principles, utilization management, length of stay management, and/or transition/discharge planning.
• Knowledge of current nursing principles, techniques and procedures.
• Demonstrated ability to deal with conflict in a positive manner. Has an awareness of, responds to, and considers the needs, feelings and capabilities of others.
• Strong communication skills with demonstrated ability to express ideas and information clearly and concisely in a manner appropriate to the audience.
At North Memorial Health, we’re on a mission to change healthcare. We’re delivering unmatched customer service and empowering our customers throughout Minnesota and Western Wisconsin to achieve their best health. North Memorial Health is a leader in delivering advanced medical care from Emergency, Urgent Care, Specialty Programs and Services, Primary Clinics, Ambulance and Air Medical Transportation.