Utilization Review Manager - Home Care jobs in Burlington, VT

GENERAL SUMMARY:

The Utilization Review RN monitors, collects and analyzes data and evaluates variances of resource utilization, complications and overall quality of care based on benchmarked criteria or established practices. The Utilization Review RN in utilizing these skills assists the Medical Center in providing optimal care in a cost effective manner and promotes the efficient and effective use of patient services. The Utilization Review RN role in data collection, analysis and summarization supports the Medical Center’s performance improvement/quality program, risk management, clinical pathway development and outcome measurement using guidelines from third party payors and external agency review processes. The Utilization Review RN utilizes his/her skills to coordinate internal and external resources to facilitate appropriate resource management of an age specific patient population which spans from newborns to geriatrics, identifying opportunities for process improvement, high risk cases and sentinel events, to the achievement of an acceptable outcome.

QUALIFICATIONS:

1. Current New York State Registered Nurse license required.
2. CCM Preferred. Utilization review and discharge planning experience preferred.
3. Three years of broad clinical nursing experience is required.
4. Quality assurance/risk management experience preferred.
5. Experience with interqual preferred. Knowledge of MCG a plus.
6. A high level of interpersonal skills and professional poise to interact with Medical Staff, other department staff, and Medical Center management is required.
7. Knowledge of the prospective payment system and current insurers payment methodologies, coding and sequencing, and data collection and analysis is preferred.
8. Assessment and goal setting skills, project management skills, and problem solving skills are required.
9. Knowledge of Medicare, Department of Health, and The Joint Commission regulations is preferred.
10. Knowledgeable in managed care processes is preferred. Computer experience preferred. 11. Good written and verbal communication skills.