Utilization Review Case Manager Jobs in Trumbull, CT

SCOPE OF POSITION:

Under the general supervision of the Director, nurses in the Case Manager role provide clinically-based case management to support the delivery of effective and efficient patient care. Paces cases from physiological and economic perspectives. Has overall accountability for the utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement. Utilizes criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, creates a discharge plan appropriate to the patient's needs and resources.

RESPONSIBILITIES:

1. Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents information in the current electronic medical record and designated databases.
2. Validates admission and continuing stay criteria with third party payers (including onsite and telephonic Case Managers) as well as Primary Care and Attending Physicians. Recommends alternative care sites where appropriate.
3. Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent the denial where possible.
4. Supports the effective prevention and management of denials, including drafting appeal letters and/or providing information as part of the appeal process.
5. Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a plan for discharge.
6. Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan. Supports the process of patient choice in establishing a discharge plan.
7. Uses clinical knowledge and knowledge of anticipate response to treatment to assess patient progression towards anticipated outcomes. Communicates and coordinates with the patient/family and health care team to Intervene when progression is stalled or diverted. Addresses actual/potential barriers to discharge
8. Completes the interventions necessary for discharges to home with self-care, home with services and short term skilled nursing facility placement. Assembles necessary referrals, discharge summaries and pertinent information for placement prior to the day of discharge.
9. Actively contributes to, participates in, and follows through on interventions identified in care coordination and complex patient rounds.
10. Identifies high risk patients and creates a collaborative plan to address their unique needs.
11. Key stake holder in the patient throughput process, supports safe and expeditious transition of patients.

REQUIREMENTS:

• Strong interpersonal, communication, and negotiation skills.
• Ability to form positive, collaborative relationships with hospital staff, patients and

families.

• Ability to effectively negotiate with internal and external providers of patient care services.
• Analytical abilities to assist in obtaining solutions to problems.
• Able to work independently and prioritize work.
• Able to manage multiple priorities.
• Basic knowledge of computers and clinical applications.
• Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge.
• Communicate in a clear, concise, and logical manner in oral and written presentations.
• Minimum of 5 years of broad clinical experience, predominately in medical/surgical nursing.
• Case Management, discharge planning and utilization review experience preferred.
• Licensed as a Registered Nurse in the State of Connecticut.
• Graduate nursing program ( Diploma/Associates) BSN preferred or actively working towards BSN.
• Case Management certification preferred