Utilization Review Case Manager -Registered Nurse

Work Schedule:

• Variable Shift 
• Weekdays/Weekends
• For Information on Employee Benefits and WSNA Contract

Salary Range: $38.42 - $57.62 

Other Compensation: 

• BSN (or higher) premium - $1.00/hour
• Certification premium - $1.00/hour

Duties:

Discharge Planning

• Identifies patients at risk for encountering problems post-hospitalization through performing a comprehensive assessment of patient discharge needs and assists to facilitate a referral for appropriate discipline/team members and outside agencies for facilitating safe and appropriate discharge plan.
• Identification of community resources and coordination of referral.
• Ability to prioritize and manage daily workload. This includes the ability to continually analyze and evaluate daily assigned caseload and prioritize the patients that require an initial or on-going discharge assessment, readmission risk assessment or discharge plan, which patients are discharging and need post-hospital placement and continued follow-up care needs.
• Assure timely and appropriate documentation of discharge and risk assessments, discharge plan, utilization management and follow-up care to assure safe and cost efficient continuity of care.
• Works with patient and interdisciplinary care team members to coordinate and implement patient discharge planning.
• May collaborate with community resources and be a liaison between Care Management and agencies as appropriate for the benefit of discharge planning.
• Communicates patient discharge plan with appropriate stakeholders.
• Documents clearly all assessments, interventions and planning in a clear, concise, accurate and timely manner.
• May perform initial and concurrent medical record review for third party payers.
• May review medical records for medical necessity of hospital admission and continued stay using Interqual or other assigned guidelines.
• Educate and include patient and family in transition planning in preparation for discharge and provides updates and/or changes throughout the hospital stay.
• Contact and arrange placements to skilled nursing facilities, rehab, long-term care, specialty care, home health agencies.
• Other duties as assigned dependent upon training and scope of practice.

Utilization Review

• Works in collaboration with Physician Advisor and commercial payors to perform prospective, concurrent and retrospective reviews to determine if patient level of care is determined to be medical necessary.
• Performs Risk Assessment for all new admissions to determine need for assignment to Discharge Planning for a comprehensive face to face patient assessment to identify and plan for appropriate discharge plan.

Skills/Qualifications:

• Strong verbal, written and interpersonal communication skills.
• Strong organization skills with the ability to work independently or as part of an interdisciplinary team in a fast paced environment.
• A high level of maturity, professionalism and discretion in daily interactions with patients, families and interdisciplinary team.
• Timely and effective communication with patients, families, providers and interdisciplinary team.
• Assure excellent customer service is provided to all stakeholders inside and outside the organization.
• Knowledge of discharge planning, utilization review, CMS criteria related to patient status and general payor reimbursement requirements.
• Strong analysis/problem solving skills.
• Computer skills to include proficiency in keyboarding and data entry.
• Critical thinking skills, able to assess, evaluate and teach.
• MS Office proficiency preferred.

Requirements:

• Minimum of three (3) years’ experience in a hospital setting with medical/surgical experience; may have equivalent combination of education and/or experience.
• One (1) year experience in discharge planning, case management and/or utilization management experience.
• Must maintain active RN license issued by the WA Department of Health.
• Graduate of an accredited school of nursing; advanced education to include BSN preferred.

Work Environment

The work of this position is performed inside, exposing the employee to indoor environmental conditions, protected from weather conditions but not necessarily from temperature changes. The employee may be exposed to dust, pollens, pollutants, fumes, communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations and other conditions common a health care environment. The noise level in the work environment is usually moderate.

Physical Demands

Requires sitting and standing associated with a typical office environment; should have the hand-eye coordination and manual dexterity needed to operate a keyboard, photocopier, telephone. Normal range of hearing and eyesight to record, prepare and communicate appropriate reports are required; close vision, distance vision, color vision, peripheral vision, depth perception and the ability to focus. Reasonable accommodation can be made to enable people with disabilities to perform essential functions of this position in relation to the physical demands detailed above

Salary Range: $38.42 - $57.62