Case Manager/ Utilization Review

Under the general supervision of the Manager, 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.   

This opportunity is Registry Role 8am - 4:30pm. Rotate every other weekend

ESSENTIAL DUTIES AND 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 system (such as MIDAS).

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