Description:
\t\t\t\t\tAs a part of the Utilization Management team the Utilization Review RN is a member of the Care Coordination team. The goal of care coordination is to assist in managing care, cost, and outcomes across the continuum of patient care as it relates to acute inpatient stay and post-acute facility stay.The Utilization Review RN Coordinates continuing care/outside services for value based risk members (HMO members) in collaboration with the hospital and primary care physician. - Responsible to repatriate stable members from nonmember facilities in the emergency department and inpatient setting- Monitors the patients in Skilled Nursing Facilities and out of network admissions using InterQual and makes assessments regarding appropriate lengths of stay- Screens for appropriateness of care and talking to the outside physicians to establish stability to and appropriateness of transfer-Coordinates an appropriate post-hospitalization treatment plan and evaluates effectiveness. -Must have proficient knowledge of evidenced based criteria such as Interqual to review for appropriate care.- Coordinates with Care Coordination Team to hand off care to the outpatient care management team- Coordinates with hospital care management team to facilitate the patient's individual needs. Makes plans to resolve unexpected care requirements. Anticipates and identifies variances in the care process related to those identified needs.- Collaborates with the health care team for quality improvement (primary care physician, social workers, pharmacists, home visit providers, care coordination support staff).- Responsible to ensure all discharges needs are being directed to contracted in-network vendors when possible. Must be knowledgable of utilization management criteria, contract vs. non-contracted.- Must be familiar with health plans, HMO, PPO, Medi-care fee for services, ACO, Medi-Cal, Medi-Medi and CalMediConnect product lines.- Working knowledge of Medicare guidelines as it relates to length of stay, covered bed days, issuing denial notices, working with Livanta, issuing DENCs and NOMNCs.- Responsible to create initial profile on all admitted patients, acute, SNF, LTAC, OON providing description of the reason for admission and providing evidence by using InterQual that the admission was appropriate.- Oversees discharge process for a select group of patients and delegates specific tasks to within scope of practice to Discharge assistant.
\t\t\t\t\tSkills:
\t\t\t\t\tUtilization review, prior authorization, Care management, Case management, interqual, ncqa, ncqa standards
\t\t\t\t\tTop Skills Details:
\t\t\t\t\tUtilization review,prior authorization,Care management
\t\t\t\t\tAdditional Skills & Qualifications:
\t\t\t\t\tCalifornia RN LicenseBLS AHAMust be experienced with Care Management Prior AuthorizationsAcute Outpatient experience- Five or more (5+) year's clinical experience required.- Three to five (3-5) years Utilization Management experience required.- One to three (1-3) years recent care management prior authorization experience- Graduate of an accredited school of nursing (Bachelors of Science in Nursing and/or Master's level degree preferred)- Experience working with health plan auditors preferred.- Current CA Registered Nurse (RN) license.- Working knowledge of InterQual preferred.- Knowledgeable of NCQA and ICE preferred.
\t\t\t\t\tExperience Level:
\t\t\t\t\tExpert Level
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