IP Case Manager/Utilization Review

Winnebago Comprehensive Healthcare System•Winnebago, NE

About The Position

This position is responsible for providing Utilization Review and Case Management services for patients in the Twelve Clans Unity Hospital and patients referred to the private sector through the WCHS Purchase Referred Care Program.

Requirements

Associate's Degree required; Bachelor's Degree preferred and one-year proven experience as a Case Manager or Utilization Review or combination of education and applicable experience
Must possess a valid full and unrestricted Professional license as a Registered Nurse in any state of the United States of America, the Commonwealth of Puerto Rico, or a territory of the United States.
Must have excellent communication skills and can relate easily to both patient and providers.
Must have an understanding of the InterQual review criteria.
Must possess the ability to read, write, and speak the English language fluently.
Must be able to continually and effectively employ professional verbal and written communications skills.
All applicants will comply with 45 CFR 1301, Subpart D, Section 1301.31, C and D, which require all prospective employees to sign a declaration prior to employment regarding all arrests and convictions of child abuse or violent felonies and to comply with PL 101-630 and PL 101-637 regarding criminal records check.

Responsibilities

Demonstrates the WCHS core Mission, Vision and Values
Responsible for conducting timely reviews of all request for services required to meet medical necessity criteria to include reviewing pre-certification for outpatient and inpatient services, applying criteria to inpatient admissions and performing concurrent review functions, identifying discharge and case management needs.
Provides clinical oversight and direction for all PRC Catastrophic Health Emergency Fund cases submitted for reimbursement.
Evaluates clinical information submitted by providers against InterQual criteria and Medicare admission and discharge criteria.
Utilizes clinical information to determine if criteria for medical necessity are met. Utilizes professional judgement to determine if additional information is required, then follows through to obtain additional information prior to making a decision.
Documents all pertinent case information and dispositions for approvals and denials. Refers all cases failing to meet InterQual criteria to Clinical Director for review and final determination.
Communicates with providers to initiate/coordinate outpatient services/discharge planning needs for patients.
Acts as a liaison to assure services are being provided to patients referred to private sector hospital for specialty referral care.
Performs other duties as assigned.
Makes decisions in matters of significance