RN Case Manager/Utilization Reviewer - Utilization Review
Company: Lubbock Heart Hospital
Posted on: September 23, 2022
RN Case Manager/Utilization ReviewerShift: Full Time Days with
Registered Nurse (RN) who must possess the ability to review
medical records in order to develop, implement, and evaluate
individualized patient care and discharge plans and assesses both
current and past medical records for appropriateness of services,
level of care and length of stay. Duties include case management,
discharge planning, advocating for patient welfare, serving as a
liaison between patients, their families, and healthcare providers
and ensuring provider and facility resources are utilized
* Screen for medical necessity for status of patients who are
admitted as an inpatient, placed in observation and/or outpatient
services or outpatient in a bed utilizing pre-approved medical
* Review all patient admission data on a concurrent basis within
the designated time frames to determine suitability of the level of
* Identify and communicate over and underutilization of medical
* Identify and present outlier cases to the Director of Case
Management for UR Physician Advisor and Committee Discussion.
* Provide pertinent clinical information and updates as needed for
insurance companies according to contractual agreement and company
* Review and utilize the approved screening criteria to update the
condition and progress of the patient.
* Collaborate with attending physician if the case does not meet
admission or continued stay criteria. Refers unresolved issues and
questionable reviews to the Director of Case Management.
Screen for post hospital needs of patients and develop discharge
plans in collaboration with patients, families and/or significant
others and healthcare providers based on patient's resources and
availability of services.
* Provide emotional support and resources to patients, families
and/or significant others. Screen for treatment eligibility.
* Make arrangements for additional services as needed to ensure a
prompt transition of health care services and help patients achieve
a positive outcome.
* Coordinates with nursing to help with discharge teaching.
* Works with other agencies to identify placement, transportation,
funding, medications, and other protocols as needed in a cost
Documents all utilization review activity in the patient's
electronic medical record. Documentation must be complete and
timely for multidisciplinary use.
* Performs both current and past medical record reviews as
requested for denials, appeal reconsideration, etc.
* Works within payer timeframes to write appeal letters and provide
supporting documentation to insurance companies as requested. These
will be submitted to Billing to submit the appeal.
* Analyzes denials of insurance claims or coverage of medical
treatments and procedures.
* Routinely attends UR Committee meetings to report on denial area
specifics, trends and corrective actions.
* Works closely with Patient Billing and Clinical Documentation
Specialist to identify trends and issues requiring corrective
* Develops and maintains an effective working relationship with
physicians and staff.
Prepares and maintains essential records and reports.
* Identifies and implements actions to improve clinical
* Organizes time and sets priorities to accomplish work load.
* Deals with conflict and problematic situations in an open,
respectful, and tactful manner.
* Supports, assists, and adheres to implementation of the
organization mission and vision.
* Organizes use of resources to assure efficient operation.
MINIMUM KNOWLEDGE AND SKILLS REQUIRED
* Three to five years' case management experience in a hospital
* Knowledge of Milliman criteria, CMC Conditions of Participation
and Federal Register concerning utilization review and meaningful
Analytical ability to collect and interpret information from
* Ability to apply professional principles in performing various
* Proficient in summarizing the information and data in order to
solve problems or design relatively complex systems and
* Able to counsel and educate patients and their families.
* Perform other duties requiring a comparable level of
* Possesses the analytical ability to resolve complex problems
requiring use of basic scientific, mathematical, or technical
principles and in-depth, experience-based knowledge.
* Must possess excellent verbal and written communication
* Comprehensive computer and database skills, including Microsoft
Office - Word, Excel, PowerPoint, Outlook.
* Must be able to work within the scope of a State of Texas
Registered Nurse License in a patient care area or professional
MINIMUM EDUCATION AND EXPERIENCE REQUIRED
* Graduation from an approved Nursing program, Bachelor Degree in
* A minimum of 5 years' acute care experience
* A minimum of 3 years' Case Management experience preferred
* Certification in Case Management desirable
LICENSURE AND CERTIFICATION
* Current Registered Nurse licensure in the State of Texas.
ENVIRONMENTAL AND PHYSICAL REQUIREMENTS
* Works in temperature controlled environment.
* Must be able to read, write and speak English fluently, have
cognitive skills for math, reading, filing and sterile technique
skills. Vision for near, mid-range, far and accommodation. Hearing
for low, medium, and high pitch.
* Communication skills to deal well with employees, patients,
families and physicians.
* Requires physical ability for standing/walking for long hours,
sitting, crouching, kneeling, reaching above head and below
* May be required to move heavy equipment or assist in moving
* The ability to work with group or team.
* Must deal calmly and effectively with high stress situation.
* Potential risk of exposure to blood-borne
Keywords: Lubbock Heart Hospital, Lubbock , RN Case Manager/Utilization Reviewer - Utilization Review, Executive , Lubbock, Texas
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