Utilization Management RN

Utilization Management RN (TX)

JOB SUMMARY: Performs technical and administrative work required to evaluate the necessity, appropriateness and efficiency of the use of medical services procedures and facilities.  Registered Nurse responsible for clinical review of all hospital services for appropriateness based on medical criteria.  This individual is responsible for the management of inpatient resources necessary and appropriate for achievement of desired impatient outcomes and the coordination of alternative levels of care for membership.

 

PRIMARY RESPONSIBILITIES:Performs on-site and/or telephonic review of inpatient services on admission.Predicts and plans for patient?s needs from pre-admission, through inpatient care and post-discharge.Utilizes pre-approved criteria and guidelines to validate medical necessity of continued stay and appropriateness of treatment and discharge planning.Acts in conjunction with the Director of Utilization Management and the Manager of Medical Management on a daily basis to assess the inpatient census for appropriate alternative health care service needs.Coordinates with appropriate discharge planning team members, hospital utilization management department and physicians to coordinate timely inpatient discharges.Strives to maintain quality care while minimizing resource use and decreasing inpatient length of stay.Identifies and reports any quality or utilization issues to the Medical Director.Acts in conjunction with the Health Plan Case Managers related to discharge planning e.g., home care, hospice care, rehabilitation care, special program care, transitional care, occupational therapy, speech, respiratory and physical therapy, durable equipment and disposable supplies.Serves as a resource and liaison for Utilization Management LVN.Documents all  activities in the Information system on a timely basis.  Updates and closes out all hospital admissions at time of discharge. Participates in daily rounds with the Medical Director.  Presents criteria based report of patient status.Conducts retrospective inpatient reviews when requested.Utilizes excellent customer service principles to assist internal and external customersMonitors and facilities appropriate utilization of resources utilizing Interqual criteria.Tracks and reports trends of inappropriate utilization of resources to the Medical Director.Supports multi-disciplinary strategies to reduce LOS, reduce resource consumption and achieve positive patient outcomes. Functions as a resource to physicians and associates regarding approved criteria, practice guidelines and alternative treatment options.Maintains clinical expertise in NICU specialty area.Utilizes effective communication, conflict management and negotiation skills.Participates in Quality Improvement ProcessOther duties as requested or assigned.

 

JOB REQUIREMENTS

Education and experience:

1.  HMO experience preferred

2.  Associate degree in nursing from an accredited school of professional nursing

3.  Minimum of 3 years NICU experience

4.  2-3 years of prior clinical experience in Utilization Management

5.  Discharge planning, community health experience a plus

Certification and Licensure:

1.  RN required with current Texas  license

Knowledge and Skills:

1.  Multi-talk oriented

2.  Ability to handle complex clinical situations with emphasis on managed care

3.  Self-confidence, ability to deal sensitively and diplomatically with difficult situations

4.  Appreciation of cultural diversity and sensitivity towards target population

5.  Computer literate

6.  Bilingual a plus

7.  Problem solver

8.  Appreciation of cultural diversity and sensitivity towards target population

Physical Requirements:

1.  Must be able to operate a computer.

2.  Must be able to operate a telephone.

3.  Must have a valid driver?s license and access to a motor vehicle

 

 

Apply on-line at www.amerigroupcorp.com