- **This position will require to be in office 4 days a week*
- Responsible for preauthorization initial and concurrent review of all inpatient, behavioral health, home health care services (skilled, non-skilled, private duty, behavioral home services) utilizing Internal criteria, InterQual® and/or nationally recognized criteria sets, clinical review of pediatric and young adult members for all in-patient stays, respite, home care, outpatient, rehabilitative therapy, durable medical equipment, and long term care services based on standardized criteria. Responsible for both the management of resources and the achievement of desired outcomes for members with on-going communication to the Director of Utilization Management, the Chief Medical Director and staff for the development and coordination of care, discharge planning and continued management of members.
Minimum Education High School Diploma or GED (Required) Bachelor's Degree (Required)
Minimum Work Experience 3 years of sound medical/surgical, home health care, pediatric and/or behavioral health experience (Required) 2 years Experience in utilization management in a managed care environment. (Required)
Required Skills/Knowledge Proficiency with word processing and spreadsheets. Excellent interpersonal, organizational, and written and verbal communication skills required. Ability to handle multiple complex assignments. Strong analytical, critical thinking and problem solving skills.
Required Licenses and Certifications Registered Nurse RN licensed in the District of Columbia (Required) Certification in utilization review (Preferred)
Job Functions Essential job duties
- Ensures compliance with standard guidelines, policy and procedures and updates for utilization review and care management. Demonstrates accuracy in use of InterQual®, CMS or other approved internal guidelines. Demonstrates compliance with authorization timeliness base on assessment of past due cases. Demonstrates compliance in case closure. Demonstrates time and attendance. Demonstrates scores of at least 80%25 on inter-rate reliability testing for all InterQual®assigned modules. Demonstrates preparation and participation in daily huddles, inpatient rounds, and weekly department meeting and assigned committee meetings. Demonstrates assessment of compliance with work flow and department processes. Performs reviews within designated time frames to determine medical necessity and appropriateness of care. Demonstrates compliance with HSCSN’s Rules of Conduct. Organizes utilization management caseload based on daily volume, and complexity of individual case management processes. Performs review within designated timeframe after receiving initial authorization request to determine medical necessity and appropriateness of care. Utilizes Interqual® criteria to validate medical necessity for admission and continued stay, including the appropriateness of treatment. Evaluates the appropriate quality of care including length of stay and alternative levels of care needed. Identifies and reports quality or utilization issues to the Chief Medical Officer or their designee. Demonstrates the ability to exercise independent judgment, along with reference materials, when performing certification. Utilizes a case conceptual framework to assess and determine the viability of plan of care based on safety risk factors, community standards of practice, resource allocations and hospital policies and procedures. Integrates the UM process system wide through the coordination of communication processes with physicians, treatment team, and other staff members of the facility. Maintains current knowledge of laws, regulations, and interpretation of utilization review, Medicaid/Medicare and commercial insurance. Actively contributes as a team member to utilization of resources within the department. Conducts retrospective reviews for medical necessity and continued stay. Conducts prospective reviews for medical necessity. Determines the level of care and assesses patient’s clinical readiness for transfer and/or discharge to the next appropriate level of care; utilizes knowledge of reimbursement and managed care in decision-making. Assist the physicians in proper placement of patients in services based upon Interqual® criteria. Documents all concurrent reviews in IT system at time of review, and closes all admissions to care at the time of discharge. Participates in home health rounds with the Chief Medical Officer/Director of Utilization Management and presents an accurate and concise criteria-based report. Participates in clinical audits. Participates as a member of the Benefit Utilization Management Committee, project teams and meetings as assigned. Proactively contacts the requesting provider if review does not meet criteria or additional information is required to complete the review. Collects data accurately and in a timely manner for medical and hospital quality review functions and reports. Collaborates with appropriate staff to identify and coordinate utilization and discharge issues. Develops a collaborative relationship with the medical staff and the healthcare team for obtaining and organizing resources for patient care which are consistent with payer regulations, contract agreements and/or benefits coverage. Applies expert knowledge and skills to facilitate an accurate, thorough, population sensitive assessment of need, development and implementation of an appropriate care plan for which, when complete, will start a preadmission and continue post discharge. Ensures admissions and continued stay appropriateness and coordinates timely resources utilization accordingly with the plan of care to shorten Medicaid Avoidable Days and eliminate denials. Documents reviews, relevant information, communication, linked documents or other information in the HSCSN IT system. Documents all reviews in the HSCSN IT system within 24 hours of receipt of information. Refers case not meeting medical necessity for review and determination in accordance with department guidelines. Reports quality of care sentinel event activities to Quality and Risk Management when identified. Routes information regarding completed authorizations to home health agency and care management staff. Completes initial and reauthorization of service requests within the specified time frames. Clearly communicates, verbally and in writing, to physician /ancillary service providers. Seeks advice from UM Manager or other designated person(s) with expertise in specialty area when necessary. Protects and secures all identifiable personal health information according to HIPAA requirements. Maintains a high degree of confidentiality on all enrollee information. Develops collaborative relationship with care management staff, and other healthcare team members to implement post discharge services. Communicates, as needed, with home health provider, care manager and others regarding the start date, end date, change in level of care, or other relevant information impacting enrollee’s care. Assesses patient insurance benefits. Coordinates with providers, as appropriate. Maintains current knowledge of laws, regulations, and interpretations of utilization review, Medicare/Medicaid, commercial insurance. Assesses and evaluates patient’s insurance limitations, services needed and availability of services to fill those needs. Consistently coordinates throughout the continuum of care to ensure treatment needs are met. Ensures that all insurance eligibility information is accurate and benefits are verified. All information is accurately entered into the computer system. Communicates verification/certification problems to the physicians and/or office staff and other appropriate hospital departments. Serve as mentor, clinical trainer and resource for HSCSN staff in providing clinical insight into pediatric illness and utilization patterns in conjunction with the Director of Utilization Management and the Chief Medical Officer. Recognizes and reports problems, issues, and/or discrepancies with procedures and/or patient’s medical records to the appropriate manager for clarification and/or follow-up. Participates in department meetings with positive and constructive input. Maintains required records in an organized manner and provides reports upon request and/or as scheduled. Assists with orientations, cross training, and skill development of staff members as scheduled. Demonstrates excellent communication skills, telephone etiquette, and helpful attitude. Communicates assessment information and discharge plan to CMs. Consistently demonstrates ability to identify patients that require care manager intervention for appropriate management and planning. Works with the care managers, members, physicians, families, and hospital utilization departments to coordinate and stabilize the discharge plan. Coordinates transfers to extended care facilities thoroughly. Serves as a liaison between client and resources, always keeping the client’s best interests foremost. Consistently conveys post discharge needs (post discharge paperwork, applications, etc.) to appropriate parties following established protocols as appropriate. Establish and maintain effective relationships with outside health agencies and facilities.
