Insurance Utilization Reviewer Jobs in Virginia (NOW HIRING)

The RN Case Manager provides case management for assigned patient populations. Utilizes clinical expertise, communication and problem-solving skills to achieve optimal clinical and resource outcomes. Promotes cost-effective care by minimizing fragmentation, maximizing coordination, and facilitating patient/family movement through the health care organization. Performs patient needs assessments upon admission and at regular intervals, facilitating referrals and providing linkages to health, wellness, and post-acute care resources across the health care continuum. Promotes interdisciplinary collaboration and teamwork to progress the plan of care and discharge plan. Promotes appropriate length of stay, resource management, and care transitions to the next level of care. Must comply with all federal and state regulations surrounding the discharge process. Must possess knowledge of growth and development appropriate to age group served and incorporate plan to meet needs into plan of care.

• Collaborates with Utilization Review Nurse.
• Maintains regular contact with assigned Utilization Review Nurse throughout the day.
• Uses InterQual software to support accurate patient statuses according to ongoing medical necessity.
• Aids in the delivery of regulatory letters and patient notices related to insurance coverage/non-coverage, using support staff as appropriate.
• Ensures documentation accurately reflects the patient's condition, co-morbidities, treatment and procedures that support the most appropriate admission status and DRG assignment.
• Communicates with patients/families to ensure understanding financial implications of discharge plans
• Facilitates an interdisciplinary approach to patient care.
• Actively participates in Interdisciplinary Team Meetings on assigned units, sharing meaningful and professional knowledge to the team discussion regarding progression of care.
• Provides feedback to the health care team verbally and via chart entries regarding the patient's progress toward reaching expected outcomes or about barriers to the plan. Manages changes to the plan as necessary.
• Maintains effective communications with all disciplines to promote timely and appropriate discharges.
• Daily communication with Social Work and Utilization Review: includes case reviews, morning touchpoints, and ongoing throughout the workday.
• Coordinates care and services within the case managed population.
• Performs face-to-face assessments of patients/families when appropriate to identify individualized needs in collaboration with SW. CM will review assigned census beginning each day with their SW partner to determine patient statuses and needs for the day.
• Documentation in the medical record is completed in the appropriate time frame, accurately reflecting the plan of care and CM interventions. Complies with CMS regulations related to discharging planning documentation.
• Coordinates referrals of post-acute services such as home health (HH), hospice, and durable medical equipment (DME). Directs liaison activities to appropriately integrate with the patient and into the health care continuum.
• Facilitates appropriate referrals surrounding high-cost medications for all patients, insured or uninsured. Works with other disciplines along with support staff to obtain prior authorizations and/or co-pay information to ensure medication needs are met for discharge and do not create a barrier.
• Ensures coordination of care when patients are transferred: acute hospital to acute hospital, and jails/prisons. Communicates with outside nursing or case management staff as appropriate for smooth transition.
• Advocates for the patient and family throughout the entire episode of care.
• Participates in departmental and system performance improvement Initiatives.
• Contributes to Carilion Clinic's performance improvement activities by engaging with predictive analytic software.
• Collects and analyzes relevant patient care and fiscal data.
• Analyzes and evaluates the effect of case management on quality outcomes and fiscal parameters.
• Complies with all departmental policies and practices and fosters teamwork and professionalism.
• Summary List of Daily Tasks / Expectations of the Nurse Case Manager Role
• Participate in Unit-based IDR morning and afternoon huddles
• Coordinate referrals for DME, HH, Hospice
• Utilize predictive analytic software (example: JVION)
• Complete face-to-face patient assessments
• Communicate with assigned UR nurse and SW partner
• Reassess patients and document status of referrals, movement on barriers
• Aids in the delivery of regulatory letters (IM, HINN)
• Integrates InterQual information during unit huddles and throughout workday as appropriate
• Provides Medication Assistance to patients identified in need (RX Help, CMAP) Initiates Medication Investigations (need for authorization, obtain co-pay information)
• Communicate post-acute care needs of inmates during transitions back to jail
• Assist in acute-acute and transitions of care
• Maintain awareness and anticipate unit-based patient needs
• Provide hand-off communication of unit needs to peers during weekday/weekend transitions