Summary Conducts medical necessity reviews in accordance with the Utilization Management (UM) plan for patients that are housed on a nursing unit, to include Inpatient admissions, patients receiving Observation services and Outpatients in a Bed. Identifies delays in care. Documents and communicates findings with the care team and the payor , when necessary. Essential Duties and Responsibilities
Supports and promotes the mission and values of Covenant Health Ministry.
Conducts admission, continued stay, and retrospective medical necessity reviews using health system approved criteria.
May communicate with payor representatives regarding patients’ level of care and regarding plans for discharge.
Responsible for communicating and collaborating with internal departments (such as, patient registration, patient accounts and others), as appropriate, to verify payer source as soon as possible upon the decision that the patient is to receive services.
Perform ongoing evaluation and critical analysis of the patient’s progress to ensure that the patient’s Hospital needs are being delivered in the most appropriate setting and in a timely manner.
Seeks peer assistance and/or provides consultation regarding complex cases and/or cases that have deviated from the initial plan of care.
Facilitates education of the interdisciplinary team related to the individual patient case management goals, InterQual criteria and coverage determinations, multi-system disease processes, and payor criteria.
Identifies opportunities for improvement in processes and quality of care and communicates findings to the director of the department.
Maintains current knowledge of DNV & CMS regulations
Identifies cases in which a Hospital-Issued Notice of Noncoverage ( HINN ) or Advanced Beneficiary Notice (ABN) is warranted.
Documents outcome of review and communicates findings rapidly and accurately, assuring an appropriate order is obtained, when necessary.
Ensures payers receive complete and accurate clinical information to support assigned level of care and hospital status, as necessary, and documents as per department guidelines.
Follows established UM processes for patients not meeting criteria by utilizing second level review / Physician Advisor services.
Identifies opportunities for physician peer to peer reviews when adverse determinations are received.
Identifies and tracks delays in care / services, inappropriate admissions, and unnecessary continued days by utilization of avoidable day tracking in the electronic medical record.
Develops and maintains professional relationships with department team members and members of the medical staff.
Participates in assigned committees and reports out any significant changes or new information to the team.
Participates in activities that increase professional / clinical skills.
Demonstrates a commitment to maintain competencies and participates in those activities, which contribute to the ongoing development of self, the profession, and other members of the health care team.
Annual goals are achieved.
Attends pertinent case management/utilization review programs to maintain current knowledge of UR practices.
Acts as a role model for other case managers.
Maintains current knowledge of organizations’ policies and procedures.
Maintains/enhances professional development/skills required to function as a Utilization Review Case Manager
Completes all mandatory learning assignments within specified timeframes
Coordinates special projects as requested
Other duties as consistent with this role.
Job Requirements
Job Knowledge and Skills
Ability to manage time wisely and focus on tasks without distraction
Ability to work autonomously in an organized manner
Strong organizational and time management skills
Professional skills in human relations and teamwork
Excellent communication skills are needed.
Good computer skills are needed
Ability to work remotely as needed
Education and Experience
Registered Nurse licensed in New Hampshire required
Minimum of five years broad clinical experience preferred
Case management and/or Utilization Management experience is preferred
Certification as CCM or ACMA-RN preferred
An equivalent combination of education and experience which provides proficiency in the areas of responsibility listed above may be substituted for the above education and experience requirements.
Working Conditions/Physical Demands
Must possess the physical and mental abilities to perform the tasks normally associated with this position that involves a combination of sitting, standing, walking, bending, stooping, and reaching. Occasional lifting/carrying up to 25 lbs. Some stress related to high level of responsibility for quality care.
Americans with Disabilities Statement
Must be able to perform all essential functions of this position with reasonable accommodation if disabled.
The above statements are intended to describe the general nature and level of work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. Covenant Health reserves the right to modify position duties at any time, to reflect process improvements and business necessity.
Standard of Business Conduct
Every St Joseph Hospital employee is required to abide by the Standards of Conduct and to report any activity that appears to violate the Standards of Conduct.
Rate of pay:35.00
Rate of pay displayed reflects the beginning of the pay scale. At the time of an offer, determination of your offer will reflect your skills and experience as it relates to the position.
Covenant Health Mission Statement
We are a Catholic health ministry, providing healing and care for the whole person, in service to all in our communities.
Our Core Values:
Compassion
We show respect, caring and sensitivity towards all, honoring the dignity of each person, especially the poor, vulnerable and suffering.
Integrity
We promote justice and ethical behavior, and responsibly steward our human, financial and environmental resources.
Collaboration
We work in partnership, dialogue and shared purpose to create healthy communities.
Excellence
We deliver all services with the highest level of quality, while seeking creative innovation.
Applicants, employees and former employees are protected from employment discrimination based on race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age (40 or older), disability, and genetic information (including family medical history).
