Utilization Manager Jobs in Decatur, GA (NOW HIRING)

• Utilizes established criteria, to perform daily inpatient review activities, including prospective, concurrent, and retrospective utilization review for all members requiring inpatient admission.
• Performs an admission utilization review upon admission.
• Assesses discharge planning needs and documents assessment using designated tools in EMR for all new inpatient admissions within 24 hours and begins the discharge planning process immediately.
• Conducts a concurrent utilization review of all patients daily and as appropriate based on criteria and policy.
• Assess daily all patients for post-hospital care planning and coordinate discharge plans, ensuring appropriate level of care in the most suitable setting.
• Performs daily bedside rounds on patients and/or significant other to update on discharge planning.
• Reviews charts daily to ensure progression of plan of care and to prepare for daily discharge planning needs.
• Escalate barriers to discharge in real time after usual processes cannot affect discharge.
• Leverages written escalation pathways to ensure timely care and timely discharge for patients.
• Establishes and evolves a discharge plan in parallel with the medical plan to ensure patients discharge plan is ready at the same time as medical clearance.
• Perform and documents a social screening assessment for all patients admitted to hospital and places referrals to internal programs and social workers as appropriate.
• Prepares for and attends all scheduled rounds with physician partners and leaders to discuss clinical courses, discharge planning, barriers to care / discharge and quality concerns.
• Communicate regularly with hospitalist partners and other healthcare team members to monitor patient progress and address delays or quality issues.
• Establishes and maintains contact with patients and their families as appropriate, including the provision of education when needed and planning for discharge along the hospital stay.
• Arranges follow up appointments for medical and surgical patients who are discharged home as needed.
• Ensure that the appropriate level of care is being delivered in the most appropriate setting.
• Performs quality of care and service reviews using identified quality indicators.
• Performs readmission reviews and identifies plan of care for discharge to prevent future readmissions.
• Send appropriate referrals for post-acute needs.
• Secure post-acute services for discharging patients in advance of medical clearance.
• Remains knowledgeable of contract benefits and current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management.
• Maintains effective interaction/communication with members of the medical staff, nursing staff, complex case managers, home care review team, social workers, general reviewers, referral coordinators, and Kaiser Permanente medical offices to facilitate the inpatient utilization management process and to provide continuity of care.
• Builds effective working relationships with physicians, department staff, post-acute staff, vendors, and other departments within the health plan.
• Assists in the development and revision of guidelines, pathways and protocols.
• Coordinate case conferences for complex cases and facilitate transfers to appropriate facilities.
• Documents a daily progress note in EMR with evolving discharge plan
• Refers cases identified as risk or quality issues to the appropriate department for review using the appropriate reporting tool.
• Document Review Activities to include (according to policy): Medical necessity for admission. Medical necessity for continued stay. Estimated length of stay. Diagnoses. Procedures performed. Demographic Data. Discharge Planning. Physicians are involved in care.
• Issue letters of non-coverage to members not meeting inpatient level of care criteria per established criteria and policy and procedure.
• Works cross-functionally with other departments in striving to meet organizational goals and objectives.
• Achieves and maintains an understanding of relevant state and federal regulations, criteria, and documentation requirements and laws that affect managed care, home health and case/utilization management.
• Knowledgeable and compliant with regional personnel policies and procedures.
• Knowledgeable and compliant with QRM departmental and unit specific policies and procedures.
• Participates in annual regional and departmental compliance training.
• Knowledgeable and compliant with Principles of Responsibility.
• Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and license requirements (if applicable), and Kaiser Permanentes policies and procedures.
• Responsible for assisting the Medical Office Administration, Customer Services and Provider Relations in investigating concerns and issues.
• Access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform the job.
• Demonstrates understanding of HIPAA privacy regulations by maintaining confidentiality of Protected Health Information (PHI).
• Demonstrates doing the right thing and doing things the right way is an underlying premise in all work-related activities and can identify location of copy of Principles of Responsibility.
• Develops and maintains an awareness of how to report compliance issues and concerns. Escalates compliance issues to immediate or appropriate supervisors.
• Refers to physician advisor when there is disagreement on patient class, level of care, continued stay or discharge.
• Other duties as assigned.

• Minimum two (2) years of RN experience in utilization/case management, discharge planning, quality improvement, or patient care delivery in a healthcare setting.

• Bachelors Degree in Nursing or four (4) years of experience in a directly related field.
• High School Diploma or General Education Development (GED) required.

• Registered Professional Nurse License (Georgia)
   

• Working knowledge of all relevant federal, state, local and regulatory requirements.
• Functional knowledge of computers and experience with managed health care delivery, including Medicare.
• Advanced communication and interpersonal skills with all levels of internal and external customers.
• Ability to collaborate effectively with multidisciplinary healthcare teams.
• Excellent time management skills; ability to work in a fast-paced environment.
• Experience in a health plan environment is highly desirable.

• Bachelors Degree in Nursing or four (4) years of experience in a directly related field.
• High School Diploma or General Education Development (GED) required.

Notes:

• Working primarily managing claims and appeals.
• Mon thru Fri with rotating weekends and holidays