Job Description Summary
Utilizing a collaborative approach, the Utilization Management Nurse is responsible for determining and managing medical necessity of acute inpatient and IOP admissions utilizing clinical criteria. This includes communication with the Physician's admitting patients to a Medical University of South Carolina facility and collaboration with the Physician Advisor during the review process.
Entity
Medical University Hospital Authority (MUHA)
Worker Type
Employee
Worker Sub-Type
Regular
Cost Center
CC005312 CHS - Utilization Management (IOP)
Pay Rate Type
Salary
Pay Grade
Health-28
Scheduled Weekly Hours
20
Work Shift
Job Description
Responsibility A: Assesses, develops, implements and monitors a comprehensive plan of care through an interdisciplinary team process in conjunction with the patient/family in internal and external settings.
-Accountable for current knowledge of utilization management responsibilities, including: payer information; business rules;regulatory guidelines; and policies and procedures.
-Performs initial, concurrent, discharge, and retrospective reviews on assigned caseload. Reviews inpatient medical necessitycriteria utilizing Indicia or Interqual, CHST clinical pathways, and clinical knowledge to determine appropriateness ofadmission, level of care, and continued stay.
-Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health-care facility to complywith government and insurance company reimbursement policies: Analyzes insurance, governmental, and accrediting agencystandards to determine criteria concerning admissions, treatment, and length of stay of patients.
-Combines clinical, business and regulatory knowledge and skill to reduce significant financial risk and exposure caused byconcurrent and retrospective denial of payments for services provided.
-Maintains productivity and optimum case load, delegating appropriately to maximize skills set, productivity andeffectiveness.Collaborates with Patient Access Services as it relates to inpatient authorization, predetermination, pre/prior authorization,and status changes.
Responsibility B: Ensures quality, cost-effective use of resources and facilitates access to care.
-Communicates with Commercial or MMC (Medicaid Managed Care) payers to certify inpatient days as required. Utilizes variousmethods to obtain necessary information: telephone, fax, secure email, secure web portal. Removing completed cases fromthe Epic worklist.
-Maintain accurate documentation of all communication and interventions in EMR.
-Escalate payer problems to Managed Care Contracting or Denials Management Specialist
Responsibility C: Collaborates with community health education/outreach organizations and providers to promote health for patients with complex health care needs.
-Proactively intervenes with medical necessity, or level of care denials by exercising all real-time options to overturn decision.Actions include, but not limited to,
-Request expedited appeal, use of third party Physician Advisor, facilitation of peer-to-peer with MUSC Physician.
-Identifies issues and strategies to modify and/or enhance the utilization management program.
Responsibility E: Prepares and monitors outcome data to assist in the identification of improvement opportunities.
•Identifies and monitors improvement opportunities along the continuum of care.•Monitors and tracks resource utilization and cost issues.•Identifies and reports quality of care, safety and quality of services issues and refer to appropriate Quality Management staff.•Actively participates in system-level committees to provide feedback on opportunities for improvement.
Responsibility F: Demonstrates commitment to team, flexibility, professional interpersonal, communication, critical thinking, and customer service skills
•Advances clinical expertise through attendance at in-hours education opportunities, reading journals, and attendance atconferences.
•Attends department/program meetings regularly.
•Maintains a level of productivity and quality consistent with: complexity of the assignment; facility policies and guidelines;established principles, ethics and standards of practice of professional nursing;
•Maintains confidentiality concerning patient/family issues.
•Ensures and participates in ongoing communication with other healthcare team members in order to enhance patient-centered care and department operations; collaborates with provider team to facilitate team rounds and patient-careconferences.
•Other job duties as assignedKnowledge and Skills
•The skill and proficiency in applying highly technical principles, concepts and techniques central to the UtilizationManagement profession in the coordination process and including all patients and specifically those identified withcomplex medical conditions.
•The ability to comprehensively assess and apply evidenced-based techniques used by or on behalf of purchasers of healthcare benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments ofthe appropriateness of care prior to its provision.
•Must have excellent verbal and written skills as well as be able to operate a personal computer, word processing programs,fax machine, photocopier and multi-line telephone.
•Must have excellent customer service skills, advanced communication and interpersonal skills with all levels of internaland external customers. This includes medical staff, patients and families, clinical personnel, support and technical staff,outside agencies, and members of the community.
Additional Job Description
Bachelor's degree in Nursing from an accredited school of nursing and three years’ work experience as a Registered Nurse required. Prior leadership experience preferred. One year of case management and/or utilization management work experience preferred. Staff hired prior to July 1, 2013 will be grandfathered in regards to education requirement. Must possess excellent verbal and written communication skills. Familiarity with InterQual or Milliman and Robinson screening criteria desired. Licensure as a registered nurse by the state of South Carolina or compact state required.
Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required.
If you like working with energetic enthusiastic individuals, you will enjoy your career with us!
The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.
Medical University of South Carolina participates in the federal E-Verify program to confirm the identity and employment authorization of all newly hired employees. For further information about the E-Verify program, please click here: http://www.uscis.gov/e-verify/employees
