Utilization Management RN SDH

Under broad direction from the Centralized Utilization Management Manager, is responsible for the hospital-wide Utilization Management Programs in a general acute care hospital which serves infant, pediatric, adolescent, young adult, adult and geriatric patients. Incumbent of this position is responsible for planning, developing, implementing and monitoring these facility-wide programs. Responsible to ensure cost effective and quality patient care by appropriate utilization of hospital resources. Performs highly responsible professional nursing and administrative work in accordance with established standards, criteria, procedures, rules, regulations and policies. of the agency.  Actively communicates with department heads to ensure compliance with these standards.

Team 30%
a. Completes all job requirements related to prospective, concurrent and retrospective case review and reporting quality issues identified during the utilization review process to department leaders. 
b. Notifies physicians of need for additional documentation or adjustments to treatment plan to promote continuum of care. 
c. Communicates accurate information with payor and physician to ensure coverage for services/care provided.
d. Collaborates with market staff and physicians to optimize efficiency of services provided and minimize consumption of resources. 
e.  Triages concurrent denials for potential P2P opportunities.
f.  Collaborates with facility-based physicians, Physician Advisors, and/or FMOLHS medical directors to schedule and conduct P2P calls by providing key documentation to support the admission status and post-acute placement.
g. Collaborates with Centralized Denials Management Department to coordinated appeal efforts to secure claim reimbursed on services provided.  

Service 30%
a. Performs admission review for appropriateness using established Internal criteria within 24 hours of admission/next working day. 
b. Assesses patients for needs on initial and concurrent review.
c. Notifies all involved entities when admission fails to meet criteria for admission and immediately documents information. 
c. Assists physicians with additional documentation when patients' level of care changes. Immediately notifies key stakeholders to ensure the appropriate orders are obtained and timely notifications are submitted. 
d. Monitors care/services provided to assigned patient population for potential opportunities for improvement or possible deviation from standards of care, protocols, and/or completion of core measure pathways. 
e. Oversees and takes day-to-day responsibility for effectiveness and efficiency of utilization management function.

Quality 30%
a. Ensures that appropriate priority is given to provide high quality care by ensuring guidelines are followed for core measures through concurrent chart review and follow-up with appropriate healthcare provider.
b. Communicates as needed with the utilization management physician advisors and/or medical directors on problematic cases and documents his decisions. 
c. Fosters an organizational climate that supports and promotes effective performance improvement efforts. 
d. Promptly notifies Sr. Director or Manager of possible quality issues. 
e. Employee shall conform to regulatory, customer and organizational requirements.

Other Duties as assigned 10% 
a. Initiates formal Appeals on any Denial for Inpatient Setting when indicated. 
b. When requested, adjusts personal schedule to meet department/unit needs. 
c. Maintains a professional appearance, according to job requirements, at all times participating in committees or counsels as needed