OverviewImplements and coordinates the health system’s Case Management and Utilization Review Program under the direction of the Case Management Director.
SAFETY SENSITIVE POSITION:
This position is a designated as “Safety Sensitive Position” under Act 593 of the State of Arkansas. An employee who is under the influence of Marijuana constitutes a threat to patients/customers which Conway Regional is responsible for in providing and supporting the delivery health care related services.
ResponsibilitiesESSENTIAL JOB PERFORMANCE REQUIREMENTS:
ESSENTIAL JOB PERFORMANCE REQUIREMENTS:
Customer Service
• Is polite, positive and tactful when communicating with all customers.
• Recognizes that customer needs are critical; listens and responds quickly and appropriately to complaints.
• Promptly responds to all questions/issues related to case management and utilization review.
Teamwork and Cooperation
• Demonstrates the ability to gain willing cooperation from others.
• Collaborates in problem solving; works with other departments to achieve common goals that best meet the customer needs and expectations.
• Acts to create and promote a pleasant and productive work environment.
Interpersonal and Communication Skills
• Communicates clearly, concisely and accurately in a professional manner
• Demonstrates good listening skills and can interact effectively without alienating others.
• Exchanges information willingly and in a timely manner to achieve shared objectives, keeps other informed.
• Demonstrates appropriate verbal and written communication skills
Attitude/Commitment
• Demonstrates positive attitude toward the organization in dealing with others.
• Exhibits support for, involvement in, and promotion of the values of the organization.
Honesty and Professionalism
• Adheres to the provisions of the Compliance Program.
• Provides fair and equitable treatment to all individuals in all interactions
• Maintains confidentiality and dignity of others
• Fulfills Commitments to meet deadlines.
Quality Improvement
• Open to new ideas and willing to try new approaches.
• Seeks opportunities to learn new tasks
• Willingly participates as a member of groups, teams, and committees working on process improvement projects.
Innovation and Creativity
• Experiments, takes risks, and explores ways to improve the organization through innovation and creativity.
• Facilitates innovation and creativity in others.
Planning/Contribution to Planning
• Understands and communicates the organization strategic plan.
• Anticipates and/or accommodates unplanned changes.
Accomplishment of Goals/Assignments
• Successfully completes goals, objectives, and routine operational duties in a timely manner.
• Demonstrates initiative and pursues activities which contribute to the accomplishment of goals and objectives.
• Appropriately utilizes organizational resources to achieve the goals and objectives.
Fiscal Responsibility
• Considers cost implications in all decision making.
• Promotes efficiency enhancements; actively identifies and implements cost savings/containment initiatives.
Other Duties
Provides oversight and guidance to case management staff for the following:
• Apply clinical knowledge to determine appropriate acuity levels and utilization through chart review.
• Effectively organizes workflow to consistently complete assignments in a timely manner.
• Demonstrates ability to access and effectively utilize primary sources of data.
• Obtains and maintains medical records in conformance with Medical Information policies.
• Communicates with co-workers in a manner that is conducive to positive and effective working relationships. Demonstrates respect, honesty and integrity when working with other service providers.
• Demonstrates compliance with all relevant hospital, state and federal requirements related to maintenance of confidentiality of persons, data and information systems.
• Takes advantage of opportunities made available through CRHS and other professional organizations for continued professional growth and development.
• Responsible for analysis of patient information for determination of necessity of admission or continuation of stay.
• Review for medical necessity of admission on the first working day after admission using approved review criteria.
• Reviews inpatient procedures to determine appropriate utilization and acuity level. Reviews potential for outpatient setting or swing bed utilization.
• Reviews all patients for medical necessity of continued stay, or before the next review date, using approved review criteria.
• Performs retroactive reviews, as necessary, and responds to the appropriate review agency or third party payor.
• Researches denials issued by review agencies and third party payors and responds within the specified time frames for appeal.
• Works with others on healthcare team to coordinate for patients discharge needs.
• Establishes an effective utilization review process and maintains an active, effective utilization review file system. Recommends, develops and revises policies related to the utilization review process.
• Works collaboratively with physicians, Case Management, the discharge planning process, Admissions, Central Scheduling and other CRHS associates.
• Prepares a monthly summary report for the Quality Resources Director that includes potential avoidable days; number of denials received, dollars of denials received and reasons for the denials; number of denials overturned and dollars of denials overturned; recommendations to improve utilization and reduce denials; and other reports as requested.
• Educates staff, physicians and other personnel regarding medical necessity requirements as defined by approved review criteria.
• Assists with other department functions as assigned.
PHYSICAL JOB REQUIREMENTS:
• Must be able to move intermittently throughout the work day.
• Must be able to speak the English language in an understandable manner.
• Must be of sound mind and demonstrate emotional stability in order to cope with mental and emotional stress of the position.
• Must possess sights and hearing senses, or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
• Must function independently, have flexibility, personal integrity, and the ability to work effectively with executive, supervisory, volunteer and hourly personnel as well as outside agencies.
KNOWLEDGE, SKILLS, AND ABILITIES:
• Knowledge of current case management and utilization practices.
• Ability to effectively utilize Microsoft computer software.
• Ability to effectively utilize Meditech system.
• Knowledge of CMS utilization review requirements
• Knowledge of community resources related to discharge planning.
• Strong organizational skills
• Medical record review
• Strong communication skills (verbal and written)
• Computer software skills (word processing and data management)
• Knowledge of hospital functions
QualificationsRegistered Nurse with current, active license to practice in Arkansas required.
Minimum of three (3) years general medical/surgical nursing experience.
BSN Preferred
Utilization Management experience preferred.
Supervisory experience preferred.
Computer software skills required.
