Utilization Review Manager - Home Care ensures quality and level of care for patients are up to established standards and comply with federal, state, and local regulations. Investigates and resolves reports of inappropriate care. Being a Utilization Review Manager - Home Care may require a bachelor's degree. Typically reports to a head of a unit/department. To be a Utilization Review Manager - Home Care typically requires 4 to 7 years of related experience. Contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature. (Copyright 2024 Salary.com)
Position Summary: The Utilization Review Case Manager validates the patient’s placement to be at the most appropriate level of care based on nationally accepted admission criteria. The UR Case Manager uses medical necessity screening tools, such as InterQual or MCG criteria, to complete initial and continued stay reviews in determining appropriate level of patient care, appropriateness of tests/procedures and an estimation of the patient’s expected length of stay. The UR Case Manager secures authorization for the patient’s clinical services through timely collaboration and communication with payers as required. The UR Case Manager follows the UR process as defined in the Utilization Review Plan in accordance with the CMS Conditions of Participation for Utilization Review
Experience
Required: 3 to 5 years acute care nursing experience
Preferred: Experience in case management
Education
Required: Graduate of accredited diploma, associate degree or baccalaureate degree nursing program
Preferred: BSN preferred
License and Credentials
Required: NJ RN licensure
Preferred: Certification in case management
Skills
Required: Current sound clinical knowledge; knowledge of medical literature, research methodology, financial/ reimbursement issues. Strong collaboration, communication and interpersonal skills. Excellent organizational and time management skills. Knowledge of computers, Electronic Health Records, data base systems and utilization review/case management documentation systems. Desire to work collaboratively and proactively with healthcare teams and other hospital-based interdisciplinary teams. Current knowledge of discharge planning, resource management, and care coordination in an acute care setting. Knowledge of CMS, commercial payer requirements and hospital financial/reimbursement processes. Excellent written/verbal communication skills, critical thinking skills, creative problem solving skills, good organizational and planning skills. Must be self-directed, have the ability to tolerate frequent interruption and work in a fast-paced work environment. Knowledge of funding, resources, services, clinical standards, care coordination processes and outcomes is preferred. Weekend, Holiday and on call may be required.
Bi-Weekly Hours: Per-Diem, Varied Shifts
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Preferred
Bachelor Science Nursing or better in Nursing.
Required
Registered Prof. Nurse
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