We are currently recruiting for Utilization Management Registered Nurses for a temporary project for 90-120 days. Hours are Mon-Fri, 8:30a-5:00p.
Responsible for the telephonic and fax delivery of the Utilization Management process to include assessing, planning, implementing, and coordinating clinical recommendations regarding medical necessity for admission, continued stay and the development / implementation of a basic case management treatment plan.
- Collects in-depth information regarding a patient’s clinical history, prognosis, treatment plan, response to treatment, access to care, access to personal and community resources, utilization of care, personal coping mechanisms, learning needs and financial constraints.
- Determines specific short and long-term goals, objectives, and interventions with accompanying timeframes.
- Coordinates quality health care services – overseeing clinical services provided by homecare vendors or sub-acute facilities, customer service, and competitive pricing.
- Serves as a healthcare coordinator to promote continuity and consistency in the services being provided.
- Will conduct an ongoing assessment of cases and discharge individuals from case management services when optimum status has been achieved.
- Will conduct an on-going assessment of cases and make plan modifications, as necessary, to achieve patient goals and improve outcomes.
- Screens for cases which do not meet the client specific guidelines, i.e. physician developed criteria, Medicare and/or Medicaid guidelines and refers them to the Medical Panel accordingly.
- Establishes a quality check date using client specific guidelines.
- Utilizes nursing experience and judgment in addition to the client specific guidelines when determining medical necessity and quality check dates.
- Monitors daily work flow queues and performs necessary calls to ensure completion of reviews according to department procedure and URAC guidelines.
- Responsible for maintaining expected standards developed by the quality/accreditation and compliance department.
- Performs discharge planning for the member if necessary and allowed by client contract.
- Performs accurate and completes verification of eligibility, benefits, and coverage and applies this information to the pre-certification, discharge planning, and proposal for case management processes – inclusive of optimization of benefit usage, PPO redirection and to assist with the research and coordination of funding alternatives.