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Employment Type:

Full time

Shift:

Day Shift

Description:

The Utilization Review Case Manager responsibilities include case screening, insurance approval, assurance of timely services, and facilitation of discharge with transition to the appropriate services. Assists the organization in ensuring compliance with CMS rules and regulations and conditions of participation as well as commercial payer specific guidelines to prevent denials and revenue loss. Patient outcomes are achieved through effective application of care plans, managed care concepts, appropriateness criteria, resource management, knowledge of community resources, and collaboration with other clinical disciplines.

Schedule:

Monday - Friday

7 am to 3:30 pm

8 hour shifts

Rotating weekends and holidays

Qualifications:

+ Current and valid license to practice as Registered Nurses in Iowa, BSN or approved **BA is required**

+ Case Management Certification preferred

+ Five years Clinical RN experience required

+ Diverse knowledge of community services, resources and programs

+ Previous case management experience preferred

What you'll do:

+ Works directly with members of care team to effectively ensure appropriate acute utilization management

+ Interacts with outside review agencies and payors to inform them of extended stay plan and necessity of services for complex cases

+ Assures all appropriate clinical information is provided to outside agencies to secure authorizations

+ Reviews new admissions to ensure charts are analyzed for medical necessity and assures follow up of continued stays

+ Performs resource management for identified patients by confirming and coordinating benefits and resources appropriate for the patient and family including age appropriate considerations

+ Accurately and completely documents clinical reviews in accordance with documentation standards, policies, procedures and/or guidelines

+ Focused concurrent assessments on resource utilization and supportive documentation for the medical necessity of acute admissions

+ Screening: for benefits eligibility and communicate with patient and health care team when benefits and plan of care are out of alignment

+ Communication with payors regarding the anticipated services and disciplines needed by patient and families

+ Reviews all observation statuses to evaluate appropriate setting, admission or timely discharge.

+ Provides resource utilization consultation to physicians, nurses, therapist, and others regarding criteria for placement of a patient in an appropriate level of care within MercyOne North Iowa and Network to facilitate admission and continuity of care across the continuum

+ Assists nurses, physicians, therapists and social workers in ensuring MercyOne North Iowa is successful in resource utilization management strategies.

+ Possesses case management skills to effectively manage all cases per established organizational standards

+ Discuss cases with Utilization Review Committee and/or third party entities when cases fail to meet admission, treatment, length of stay and/or discharge standards.

+ Maintains required department confidentiality and abides by HIPPA regulations.

+ Provides competent patient care to the above indicated patient populations by obtaining and appropriately interpreting data, making appropriate decisions based on demonstrated knowledge of age-specific growth and development, and appropriately adapting procedures and treatments.

+ Takes an active role in enhancing ability to carry out job functions through personal and professional/job-related growth and development and participates in medical center and/or departmental education programs.

+ Communicates with and performs duties following the philosophy of MercyOne North Iowa Medical Center and the Sisters of Mercy reflecting the organization’s Mission, Values, and Guiding Behaviors.

+ Supports and abides by all medical center, departmental, and safety policies and procedures. Proactively identifies safety concerns surrounding the work environment.

+ Performs other responsibilities as requested by supervisor, director or department head

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran