Case Manager Utilization Review Nurse Jobs in Murrells Inlet, SC

While the various roles of the RN-Case Manager fall under the same job code, each RN-Case Manager works primarily in one of three functions: Bed Control, Utilization Review, or Discharge Planning. While the RN-Case Manager may serve in one of these focused areas, the RN-Case Manager may be asked to move to various areas of focus as deemed necessary by the needs of the department.

Qualifications:

Education: Associate degree (AS) in Nursing required. Bachelors degree (BS) in Nursing preferred.

Experience: Minimum of two years current experience in nursing practice required. Previous experience with reimbursement and pre-certification practice preferred. Previous specific experience as a RN case manager in an acute care setting preferred.

Licensure/Certification/Registration: Current licensure as a Registered Nurse in the State of South Carolina in good standing (SCLLR) required.

Duties and Responsibilities:

Bed Control: Participates in the coordination of care and service of a patient population across a continuum of care. The RN-Case Manager will communicate with physicians and nurses regarding emergency and direct admissions based on bed availability, treatment plan and admission criteria; initiate and maintain communication throughout the day with Emergency Department, Operating Room, and specialty area. Attend daily care coordination rounds; strategize and recommend anticipated placement of patient to appropriate unit at appropriate time. The RN-Case Manager will collect, analyze, evaluate and summarize data from referring hospitals, attending physicians, referring physicians and clinics regarding bed utilization; assess scheduled admissions, available beds and requested patient transfers on an on-going basis. The RN-Case Manager will ensure compliance with standards related to pending discharges for current and following day in coordination with case managers. Collect, investigate and disseminate clinical data to other Patient Access Service personnel regarding diagnosis and treatment plans and insurance data for evaluation of admission criteria.

Utilization Review: Participate in the coordination of care and service of a patient population across a continuum of care. Perform and coordinate the initial assessments and ongoing reassessments of the patient’s status, document patient case information within a database system, and perform chart review/audits monthly or as needed. The RN-Case Manager ensures that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing patient treatment files, the RN-Case Manager will ensure that patients do not receive unnecessary procedures, ineffective treatment, or unnecessarily extensive hospital stays. The RN-Case Manager reviews precertification requests for medical necessity. Initiate elective pre-certification and coordinate urgent/emergent admission authorization; coordinate out of network admission, lack of referral from primary care provider, no insurance, and other special admissions with attending physicians and others. Refer long-term diagnoses, length of stay more than five days and other high-risk diagnoses to case management to ensure that patients remain on proper clinical pathways.

Discharge Planning: Participate in the coordination of care and service of a patient population across a continuum of care. The RN-Case Manager will participate in monthly case conferences by providing information pertinent to patient’s needs/goals as well as partner with the Program Director in development and review of the patient’s individualized coordination of care plan. The RN-Case Manager will ensure that the patient’s medical needs are addressed; consult with the patient’s physicians as needed, coordinating plans of treatment, and advocating for the patient when necessary. Identify and assist patients in accessing entitlements, resources, information, and referrals for psychosocial needs. Empower patients in decision making for care planning. Maintain accurate and timely patient information, which is readily accessible for review and meet all requirements; assist in data collection for reporting/funding sources. Completes other duties as assigned by department leadership.