Employee is expected to cheerfully and enthusiastically carry out tasks and responsibilities of the job, including but not limited to, high quality professional patient care, thorough and accurate documentation, a willingness to work closely with physicians, administrators, coworkers, and supervisors. Prompt assistance to other units/ departments is expected as well as prompt assistance within the employee’s own unit/ department. By following the guidelines outlined in this job description, high quality patient care will be assured, and the continued success of Curative.

 

ESSENTIAL FUNCTIONS:

• Interacts with providers, facilities and their staff regarding pre-certifications, concurrent review, discharge planning, retrospective review, redirections, denials, appeals and complaints 
• Formulates and promotes continuity of care assuring appropriate medical treatments, processes and utilization of resources 
• Provides concurrent review by assessing the medical necessity and the appropriateness of acute inpatient, SNF and custodial care in order to justify the continued level of care and identification of avoidable days due to barriers to care 
• Provides discharge planning and continuity of care activities including but not limited to home care, DME coordination, follow up with primary care and/or specialist 
• Collaborates with the Medical Director of Curative, Medical Management Manager and Director of Case Management to develop and implement ways to decrease hospital stays in a medically safe and responsible manner incorporating criteria based concurrent review techniques, within the parameters of the patient’s health plan 
• Reports monthly avoidable days, significant interventions and quality triggers. 
• Work in close coordination with home care delivery systems, outpatient providers and other community agencies to assure follow through of the Utilization Management effort 
• Communicates service delivery problems to Manager as identified through the Utilization Management System 
• Receives and reviews written and verbal requests for patient services 
• Reviews all requests for appropriateness according to established guidelines and coordinated review with plan benefit guidelines 
• Receives and reviews requests for services and approves or refers requests for Medical Director review when criteria are not met 
• Enters authorizations/ pre-certifications into the Utilization Management System 
• Communicates with Claims and Customer Services on the status of requested services through the Utilization Management System 
• Accurately codes appropriate diagnosis and procedures into the Utilization Management System according to ICD.10 and CPT guidelines 
• Communicates outcome of referral reviews to physician and/ or other office staff and provides authorization numbers 
• Participates in special projects as required 
• Researches complex cases as needed under the direction of the Manager or Medical Director

• Performs other duties as assigned.

 

MINIMUM QUALIFICATIONS:

Education: Associate or Bachelor Degree in Professional Nursing

Experience: At least four years of clinical experience in hospital nursing such as Critical Care/ER/Med Surg/Home Health. One to two years of utilization/case management (managed care preferred). One to two years of concurrent review or retrospective review with an emphasis on discharge planning.

Knowledge, Skills and Abilities:

● Current knowledge of services provided across the continuum of care that involve multiple systems addressing the ongoing needs of the patient

● Knowledge of discharge planning

● Familiarity with community agencies and with how to make appropriate referrals to them

● Knowledge of different hospital reimbursement methodologies and concurrent review criteria

● Excellent verbal and written communication skills

● Computer skills

● Ability to identify ways to decrease hospital days in a medically safe and responsible manner

Certificate/License: Texas RN licensure

PHYSICAL DEMANDS: SEDENTARY (requires lifting up to 10 lbs., carrying small objects)

WORKING ENVIRONMENT:

Definitions for OSHA working environment are: Category I: Involves routine exposure to blood or body fluids. Category II: Involves possible exposure to blood or body fluids. Category III: Involves no exposure. OSHA category for blood born pathogens for this position is a III.