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RN Case Manager/Utilization Reviewer - Utilization Review

Company: Lubbock Heart Hospital
Location: Lubbock
Posted on: November 23, 2022

Job Description:

RN Case Manager/Utilization ReviewerShift: Full Time Days with Occasional Call


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 appropriately.


* 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 necessity guidelines.
* Review all patient admission data on a concurrent basis within the designated time frames to determine suitability of the level of care.
* Identify and communicate over and underutilization of medical services.
* 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 policies.
* 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 effective manner.

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 action.
* 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 services.
* 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.


* Three to five years' case management experience in a hospital setting preferred.
* Knowledge of Milliman criteria, CMC Conditions of Participation and Federal Register concerning utilization review and meaningful discharge process.

Analytical ability to collect and interpret information from diverse sources.

* Ability to apply professional principles in performing various analyses.
* Proficient in summarizing the information and data in order to solve problems or design relatively complex systems and programs.
* Able to counsel and educate patients and their families.
* Perform other duties requiring a comparable level of communication skill.
* 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 skills.
* 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 office environment


* Graduation from an approved Nursing program, Bachelor Degree in Nursing preferred.
* A minimum of 5 years' acute care experience
* A minimum of 3 years' Case Management experience preferred
* Certification in Case Management desirable


* Current Registered Nurse licensure in the State of Texas.


* 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 waist.
* May be required to move heavy equipment or assist in moving patients.
* 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, Healthcare , Lubbock, Texas

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