Case Manager of Utilization Review
Utilization Review CM role supports the North Texas Case Management departments in admission and concurrent review adhering to medical necessity and Corporate Compliance guidelines. This virtual role reviews new patient admissions and concurrent using Meditech and other information sources and integrates patient clinical data with the appropriate selection of InterQual (IQ) Criteria. As such travel may be involved to the hospital facilities as needed.
GENERAL RESPONSIBILITIES (The essential responsibilities and accountabilities of this position including interactions with other departments and outside vendors, if applicable.)
a) Performs admission review and concurrent review to determine the clinical appropriateness and medical necessity of the level of care ordered by the physician by applying Interqual criteria
b) Initiates timely initial and concurrent reviews per managed care payers contract
c) Maintains current knowledge of regulatory guidelines for Utilization Review
d) Demonstrated IT ability to become MIDAS expert and work with Corporate Case Management MIDAS for enhancements for North Texas CM departments.
e) Demonstrated ability for process improvement in the design and standardization of workflow related to the admission UR process for standardization across all of NTX. This will also lead to competency/new orientation checklist development.
f) Communication with the Case Manager and/or Social Worker as indicated to assure timely intervention for resources, discharge planning, or medical necessity.
g) Expedite timely response on cases requiring external physician advisor reviews and/or follow up of cases with status determination after normal business hours.
h) Work closely with the Utilization Review Coordinator to assure authorization of days based on clinical data provided
i) Provide subject matter expert support for Interqual and Midas to team members in facilities
j) Demonstrated ability to mentor members of the team and lead process changes and communicate these changes in a positive growing experience for CM members.
k) Ability to work with the Denial Manager and NTX Division Director to initiate change to impact NTX and Corporate goals in the area of denial reduction, LOS opportunities and other metrics as determined
l) Demonstrates analytical and critical thinking abilities with pro-active decision making and negotiation skills.
m) Excellent communication skills (oral and written) and customer service oriented
n) Ability to establish collaborative and effective working relationships.
o) Ability to work with data for trends and use of reports.
p) Ability to travel to the NTX hospitals approximately 10% of the time on as needed bases.
q) Requirement to work late afternoon to evening hour shift and weekends
r) Other duties as assigned
• RN required.
• Willing to become a certified IQ instructor for the NTX and orient new CM in appropriate use of IQ.
• Certification in ACM, CCM, or CPUR preferred or willing to obtain within 18 months of hire.
A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom