Hospital Reviewer/Utilization Manager

Position Purpose:  Works in partnership with physicians, nurse case managers, and other disciplines to ensure the appropriateness for the corresponding level of care utilizing evidence-based criteria.  

Responsibilities:
 

• Uses a collaborative process to plan, assess, re-assess, implement, monitor, and evaluate the options and services required to meet the healthcare needs of the patients using the functions of Utilization Resource Management, Transition of Care, Discharge Planning, and Case Management.
• Reviews the appropriateness of Severity Index/Intensity of Service for all acute care admissions utilizing evidence-based criteria guidelines within the appropriate time frame.
• Notifies the Medical Director of all acute care admissions not meeting evidence-based criteria potential/actual denials.
• Presents case for patients not meeting criteria for medical necessity for the requested level of care/patient status to the Medical Director.
• Proactively identifies, and resolves delays and obstacles for safe discharge. Seeks consultation from appropriate disciplines/departments to expedite care and facilitate safe discharge.
• Communicates with multiple resources and payors to identify appropriate vendors for obtaining authorization for ancillary/hospital services to facilitate transition to appropriate level of care.
• Collaborates with family, health care team, payors, and providers to achieve appropriate resource management to implement safe discharge plan of care established by health care team and family.
• Assists in identifying and reporting variances in utilization of resources, avoidable days/denials. Works in collaboration with Appeals Management/Medical Director in the appeals process.
• Responsible for the appropriate use of software and applications, and enters case management information accurately and in a timely manner.
• Adheres to Medicare and Medicaid regulatory guidelines as it pertains to patient admission/safe discharge.
• Provides after hour safe discharge coverage for all hospital units.
• Participates in utilization management initiatives/opportunities for improvement through departmental committee assignments.   

 

• Registered Nurse or Licensed Practical Nurse.
• Current and valid license to practice as a Registered Nurse or Licensed Practical Nurse in the State of Florida.
• 3 years minimum experience in discharge planning, utilization management, or case management.
• Basic proficiency in Microsoft Word, Excel, and Outlook.
• Demonstrates commitment to the Partners-in-Caring process and the behavioral expectations in all interactions and in performing all job duties.   
• Performs duties in a manner to promote quality patient care.
• Able to communicate effectively both verbally and in writing in a clear, concise, and courteous manner.
• Fluent in Spanish preferred.
• Working experience with electronic medical records, and/or discharge planning and case management systems.
• Able to maintain confidentiality of sensitive information.
• Able to work in a fast-paced environment, and effectively manage and use resources to successfully meet the competing deadlines of a variety of tasks, problems, and projects.
• Able and available to work a flexible/rotating schedule, including holidays and weekends.

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