Works collaboratively with supervisors, providers, community resources, and facilities to establish and implement processes to support delivery of effective utilization management. Coordinates assignments to manage daily census. Acts as clinical specialist and utilization management subject matter expert for complex situations. Provides mentoring and training to other inpatient utilization review nurses. Champions compliance requirements.
Reports to: Sup. Clinical Care
Department: HS-Inpatient Care Management
Location: Kapolei, HI.
- Telephonically reviews medical information in order to determine the medical necessity of continued stay according to review standards. Determines whether treatments are consistent with member's diagnosis and appropriate level of care.
- Uses critical thinking to determine if treatments are consistent with member's diagnosis and clinical needs. Ensures services provided are within benefit plan and that appropriate contracted providers are utilized.
- Identifies needed information. Works with providers to obtain the information pertinent to evaluating treatment plan, medical necessity, appropriateness of care, timely progression of services and appropriate application of available benefits.
- Initiates interactions with providers regarding anticipated progression of care and transitions across treatment settings. Facilitates referrals for follow up providers and support services.
- Evaluates clinical information to identify and present cases during rounds. This includes identification of members at high risk for complicated medical treatment plans, readmissions potential, and admissions for potentially avoidable conditions.
- Prepares cases for review by medical director when condition or treatment plan varies from established guidelines.
- Documents clinical updates, authorizations, and referrals in the health plan care management system adhering to health plan documentation standards.
- Provides members and/or treating providers with resources to enhance their ability to access services.
- Performs other duties as assigned.
- Required A High School or GED
- Preferred A Bachelor's Degree in a related field
- Required 2 years of experience in Acute medical hospital experience (medical/surgical, emergency room, orthopedic, neurological care experience
- Preferred 2 years of experience in UM, CCM, Clinical Criteria, or other nursing specialty certification
- Preferred 2 years of experience in discharge planning
Licenses and Certifications:
- Intermediate Ability to work independently
- Intermediate Ability to multi-task
- Intermediate Demonstrated time management and priority setting skills
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Demonstrated written communication skills
- Intermediate Ability to create, review and interpret treatment plans
- Intermediate Demonstrated problem solving skills
- Intermediate Knowledge of healthcare delivery
- Intermediate Ability to effectively present information and respond to questions from families, members, and providers
- Intermediate Ability to effectively present information and respond to questions from peers and management
A license in one of the following is required:
- Required Registered Nurse (RN)
- Required Beginner Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Outlook
- Required Intermediate Healthcare Management Systems (Generic)