Utilization Management Inpatient Case Manager

Dean Health Plan has been dedicated to improving healthcare for over 25 years.  We are committed to guiding our members down a smooth path to the care that they need.  This path will encompass inpatient reviews for ongoing medical necessity as well as identification for possible case management and coordination of service that might be required on an outpatient basis.  If you are an experienced RN interested in joining a growing organization committed to quality care, we would like to talk to you about our Utilization Management Case Manager opportunity.

Position Summary:

Responsible for utilization management, utilization review, and/or concurrent review (on-site or telephonic inpatient care management). Perform reviews of current inpatient services to ensure that in-patient services are directed and managed at the most effective and appropriate level of service according to the patient's medical condition.  Determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination. 

Job Duties:

• Coordinate the management of all in-patient activities/processes, including but not limited to concurrent and retrospective reviews, authorization of appropriate lengths of stay, authorization of appropriate discharge services and equipment, and documentation of all authorized and/or denied in-patient services.
• Perform telephonic or daily on-site initial/concurrent review on identified in-patient members.  Direct pertinent clinical information/questions to the Physicians(s), Medical Director(s), UM Manager and/or Director of Care Management.
• Assist with bed day management through collaboration with the Physicians, Medical Director, and Director of Care Management.
• Review medical information from the physicians and/or facilities to assist in determining medical necessity of treatment and appropriate level of care.
• Utilize established clinical review guidelines (Milliman) for the authorization of in-patient length of stays/level of care and clinical treatment.
• Confer with the Medical Director(s), UM Manager and/or Director of Care Management when there are concerns regarding utilization of services or complicated cases.
• Utilizing a collaborative approach with the case management team, identify cost saving measures and implement cost saving interventions.  Track cost savings.
• Document all in-patient activities, decisions, review information, and final outcomes in DHP’s clinical documentation system.
• Coordinate all case management activities including, but not limited to, assignment of patients to the Case Management program, review referral authorizations submitted for patients in the Case Management program, and coordinate all required/authorized services.
• Communicate with the providers to ensure continuity of care and coordination between multiple specialists, providers, and vendors.
• Promote early and intensive treatment intervention in the least restrictive setting.
• Create individual treatment plans that are reviewed and revised as the members’ healthcare needs change.
• Provide information regarding open cases, services authorized, case outcomes to the UM and/or QI Committees.
• Report any identified quality of care issues to the UM Manager and/or Director of Care Management and Medical Director
• Actively participate in inpatient case reviews.

• Graduate of an accredited school of nursing or social work and possession of an unrestricted RN or Social Work license to practice nursing in the state of Wisconsin or eligible for unrestricted RN licensure in the state of Wisconsin. 
• Minimum 2-3 years post degree experience in acute care setting including utilization review.  Previous medical management experience required.  
• Must demonstrate broad experience in clinical nursing or equivalent healthcare educational background. At least two years of managed care experience preferred. 
• Knowledge and experience with MS Office computer programs. 
• A valid driver's license and personal reliable vehicle required for work-related travel in order to fulfill job responsibilities.

Preferred Skills:

• Strong communications skills.