Utilization Management Nurse

SUMMARY OF POSITION:

The Utilization Management (UM) Nurse is a licensed nursing professional responsible for reviewing UM cases and discharge planning activities. The UM Nurse may also assist with preparing files for audits and required reporting and ensuring UM cases are reviewed and processed within timeliness standards.

The UM Nurse will work closely with the UM/QI Manager, MSO UM team, MSO Medical Director, and MSO Physician Reviewer on UM case reviews. The UM Nurse will also work with the MSO Case Management team on coordinating patient care to ensure patients can access the necessary medical care to manage their health condition.

ESSENTIAL JOB FUNCTIONS:

• Applies clinical skills and expertise in the assessment, planning, and coordination of necessary healthcare services.
• Reviews Treatment Authorization Request (TAR) and patient treatment plans to ensure adherence to established criteria and standards.
• Responsible for the inpatient UM process, including initial and concurrent case reviews, review of inpatient skilled nursing and rehabilitation treatment requests, and facilitate repatriation efforts.
• Provides guidance to UM Coordinators on complex outpatient TARs that require clinical judgment and application of medical necessity criteria.
• Facilitates timely implementation of hospital discharge plans in collaboration with other interdisciplinary team members; arranges follow-up care as appropriate.
• Makes complex clinical decisions regarding medical care; involves Medical Directors and clinical providers to solve the complex issues.
• Collaborates with MSO Case Management team and PCPs to ensure resource utilization is appropriate; plans and implements strategies to reduce resource consumption and achieve positive patient outcomes.
• Identifies community and outpatient resources and coordinates with the interdisciplinary team to assist patients in obtaining the needed services.
• Participates in the development and implementation of effective and efficient standards, policies, protocols, reports and benchmarks that support the UM program requirements.
• Utilizes multiple systems to maintain documentation of case activities; collects, analyzes and reports on data for utilization, quality improvement, compliance, and other areas as assigned.
• Assists in training new UM Nurses and UM Coordinators and guides them in accurately completing their work.
• Provides cross coverage for MSO Nurse Case Managers and performs transition of care services, including post-discharge follow-up, medication reconciliation, home visit, and screening members for complex case management criteria. Home visits may be conducted at a public place if the patient does not have a home.
• Performs other job duties as required by manager/supervisor.