Case Manager / Utilization Review Nurse

Conway Regional•Conway, AR

18d

About The Position

Provides discharge planning and utilization review services in compliance with patient’s discharge planning needs and the hospital’s utilization review program. SAFETY SENSITIVE POSITION: This position is a designated as “Safety Sensitive Position” under Act 593 of the State of Arkansas. An employee who is under the influence of Marijuana constitutes a threat to patients/customers which Conway Regional is responsible for in providing and supporting the delivery health care related services.

Requirements

Registered Nurse or Licensed Practical Nurse with current, active license to practice in Arkansas, required
Proof of the highest level of nursing education achieved, required

Nice To Haves

At least one-year experience in the area of case management/utilization review, preferred

Responsibilities

Demonstrates initiative and pursues activities which contribute to the accomplishment of goals and objectives
Appropriately utilizes organizational resources to achieve the goals and objectives
Considers cost implications in all decision making
Promotes efficiency enhancements; actively identifies and implements cost savings/containment initiatives
Apply clinical knowledge to determine appropriate acuity levels and utilization through chart review
Effectively organizes workflow to consistently complete assignments in a timely manner
Demonstrates ability to access and effectively utilize primary sources of data
Obtains and maintains medical records in conformance with Medical Information policies
Communicates with co-workers in a manner that is conducive to positive and effective working relationships. Demonstrates respect, honesty and integrity when working with other service providers
Demonstrates compliance with all relevant hospital, state and federal requirements related to maintenance of confidentiality of persons, data and information systems
Takes advantage of opportunities made available through CRHS and other professional organizations for continued professional growth and development
Responsible for analysis of patient information for determination of necessity of admission or continuation of stay
Review for medical necessity of admission on the first working day after admission using approved review criteria
Reviews inpatient procedures to determine appropriate utilization and acuity level. Reviews potential for outpatient setting or swing bed utilization
Reviews all patients for medical necessity of continued stay, or before the next review date, using approved review criteria
Performs retroactive reviews, as necessary, and responds to the appropriate review agency or third-party payor
Researches denials issued by review agencies and third-party payors and responds within the specified time frames for appeal
Works with others on healthcare team to coordinate for patients discharge needs
Establishes an effective utilization review process and maintains an active, effective utilization review file system. Recommends, develops and revises policies related to the utilization review process
Works collaboratively with physicians, Case Management, the discharge planning process, Admissions, Central Scheduling and other CRHS associates
Educates staff, physicians and other personnel regarding medical necessity requirements as defined by approved review criteria
Attends 75% of staff meetings
Participates in committees which promote staff and medical center facility growth as directed by Director/Manager and/or CRMC policy
Attends mandatory in-services and committee meetings as assigned
Adheres to dress code, conduct and attendance policies
Participate in activities that promote personal development
Must maintain all organizational education and work requirements (i.e., Annual Mandatory Education, Competencies, BLS Provider, etc.)
Other duties as assigned by management