Utilization Review Manager - Home Care jobs in Omaha, NE

SCHEDULE: Full-time; 36 hours per week; 9-hour shifts; Monday - Friday

The RN Case Manager is responsible for coordinating each patient's hospitalization from preadmission through discharge by assessing the medical appropriateness, quality and cost-effectiveness in accordance with established criteria and policies. This review activity is performed in collaboration with patients, family, providers and other professionals and may be conducted prospectively, concurrently or retrospectively. The RN Case Manager provides case management interventions by assessing, monitoring, evaluating options and services to provide an appropriate, individualized plan for each patient across the continuum of care.

Graduate from an approved professional Nursing Program with a current Iowa RN license. Hospital experience preferred with at least two years of clinical experience. Previous experience with case management, insurance notification and Milliman Care Guidelines preferred. Knowledge of CAH regulations and compliance issues preferred. Computer knowledge required. Shows creativity and ability to accept change.

Completes evaluation of admission and continued stay for severity of illness and intensity of service to ensure appropriateness utilizing accepted criteria. Follows the Utilization Management Plan for compliance with physician review. Collaborates with medical providers by providing pertinent clinical information to promote quality patient care in an ongoing and timely manner. Notifies commercial insurance companies for admission and continued stay approval as required. Follows up on all denials and coordinates medical provider response to denials. Contacts third party payers and delivers accurate clinical information to assure reimbursement for service. Evaluates each patient for discharge needs. Formulates a discharge plan with medical provider, patient, family, members of the Inter-Departmental Team (IDT) and documents appropriately. Completes referral to community agencies as indicated. Facilitates safe patient discharge while working in partnership with doctors, nurses, therapist and outside agencies ensuring discharge plans are in place. Discusses plan with patient and family throughout the patient's stay to ensure understanding and all needs are met. Serves as a resource person for patient, family, staff and medical providers for community resources. Works independently with reliability, consistency and is detail oriented. Demonstrates strong organizational skills to manage multiple complex activities with tight deadlines. Establishes priorities. NOTE: This is a partial list of key areas. For a complete job description, please contact HR.