Utilization Management Assistant Jobs in Raleigh, NC

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About Duke Regional Hospital

Pursue your passion for caring with Duke Regional Hospital in Durham, North Carolina. With 388 beds it is the second largest of Duke Health's four hospitals and offers a comprehensive range ofmedical, surgical, and diagnostic services, including orthopedics, weight-loss surgery, women's services, and heart and vascular services.

DRH-ED 7a-7p Sat-Sun-Mon

Manage a designated caseload to coordinate and complete timely assessment, planning, implementation and evaluation of discharge plans and care transitions across the continuum of care. Ensure optimum utilization of the patient's and the Health System's resources and perform these duties within the requirements of CMS and other external review agencies.

Duties and Responsibilities

• Monitor daily census and assignment to assure all patients are assessed for case management needs including care coordination/transition and discharge planning, consultations, advocacy, education.
• Maintain effective communication with health care team members related to assessment findings, discharge planning needs and provider orders needed to arrange Homecare, Durable Medical Equipment, Transportation, Skilled Nursing or Acute Rehab Facility placement, Substance Abuse Treatment and outpatient follow-up.
• Maintain working knowledge of specific benefits and reimbursement guidelines, the discharge planning process and applicable federal, state and local regulations. Provide education and guidance on these topics to providers, patients and families as needed.
• Work with Utilization Management partners to provide information and feedback that will enhance negotiations and denial prevention with payers.
• Maintain timely documentation of assessment findings, discharge arrangements and actions taken according to departmental guidelines; prepare reports and maintain records as requested and/or required. Monitor daily census and assignment to assure all patients are assessed for case management needs including care coordination/transition and discharge planning, consultations, advocacy, education.
• Maintain effective communication with health care team members related to assessment findings, discharge planning needs and provider orders needed to arrange Homecare, Durable Medical Equipment, Transportation, Skilled Nursing or Acute Rehab Facility placement, Substance Abuse Treatment and outpatient follow-up.
• Maintain working knowledge of specific benefits and reimbursement guidelines, the discharge planning process and applicable federal, state and local regulations. Provide education and guidance on these topics to providers, patients and families as needed.
• Work with Utilization Management partners to provide information and feedback that will enhance negotiations and denial prevention with payers.
• Maintain timely documentation of assessment findings, discharge arrangements and actions taken according to departmental guidelines; prepare reports and maintain records as requested and/or required.

Inpatient Job Responsibilities/Activities

• Complete initial assessment within 72 hours to identify psychosocial strengths, weaknesses, community living supports present and needed.
• Contact with patient primary support systems to gather information regarding dynamics and needs of support system.
• Conduct support system/family therapy to allow patient/support to practice skills needed to support community living and/or assist in development of functional patterns of interactions.
• Conduct group sessions for patients focused on skill building/interactional skills.
• Assist patient in development of safety plan to promote positive coping while living in community setting.
• Facilitate discharge planning for patients, involving support systems when possible, to provide level of intervention that creates environment for crisis contacts and safe community living.
• Interface with team to determine multidisciplinary assessment of discharge planning needs and provide information regarding support system/family function.
• Update Interqual.
• Other duties as assigned.
• Typical case load is 10 patients.

Consult/Liason Job Responsibilities/Activities

• Primary responsibility is to complete assessments in ED and discharge planning for patients within the hospitals.
• Secondary responsibility is discharge planning assistance for psychiatric followup for patients being treated for a medical condition.
• Complete crisis assessments to determine level of care required for patient to move to safe community living including but not limited to reason for presentation, current symptoms and level of distress, ability to participate in treatment, safety assessment, past history of treatment, current support systems, strengths, weaknesses and primary psychiatric diagnosis.
• Facilitate discharge planning with psychiatric appointments or referrals to other facilities as determined by level of care needed.
• Facilitate tracking of IVC paperwork for all patients who are awaiting transfer to another facility.
• Interface with team for cases covered by consult service to determine multidisciplinary assessment of discharge planning needs and provide information regarding support system/family function.
• Update Interqual for patients who are not being treated for a medical condition (typically observation patients at Duke Raleigh).
• Case load varies as immediate needs vary. As a guide, 3 initial assessments and discharge planning activities for up to 6 patients could be completed during 8 hour shift. Pediatric cases take longer to complete initial assessment so the total number would be reduced if a patient is under 18.
• Provide community liaison to one mental health workgroup.

Minimum Qualifications

Education

Master's degree in social work from an accredited school of social work.

Experience

3 years of relevant experience.

Degrees, Licensure, and/or Certification

• Current licensure as a licensed clinical social worker (LCSW) by the NC Social Work Certification and Licensure Board.
• Consult/Liason should also be a Notary.

Knowledge, Skills, and Abilities

• Ability to work effectively in a self-directed role
• Ability to multi-task, capable of daily problem-solving complex issues Excellent written and verbal skills
• Basic computer skills necessary