What are the responsibilities and job description for the Utilization Review (UR) / Case Management position at Eastland Memorial Hospital?
Position Summary : The Utilization Review and Case Management Specialist ensures effective and efficient utilization of healthcare services while maintaining compliance with regulatory and payor guidelines. This role involves collaboration with interdisciplinary teams to optimize patient care. This role includes conducting, monitoring, and documenting activities within the Utilization Review Plan. Responsibilities involve : ? Developing and maintaining effective processes for determining appropriate admission status. ? Managing inpatient and observation stays to maximize throughput, meet payor guidelines, and coordinate care. ? Monitoring program effectiveness, evaluating data, reporting outcomes, and leading process improvement initiatives. ? Analyzing data to identify trends and opportunities for improvement in utilization and patient flow processes. ? Coordinating care transitions and resolving barriers to discharge.
Requirements
Qualifications : Education :
- RN required. BSN preferred.
- Personal Job-related Skills : Strong knowledge of utilization review, case management, and regulatory compliance. Excellent communication skills for collaboration with medical staff, payors, and interdisciplinary teams. Strong organizational and analytical skills to manage data and implement process improvements. Ability to use critical thinking to address complex patient care and resource utilization issues.
- Licensure, Registry or Certification : Current RN license in the State of Texas. Case Management Certification (CCM) or Accredited Case Manager (ACM) preferred.
- Experience : Minimum of two years in utilization review, utilization management, or case management in a hospital setting. Familiarity with hospital revenue cycles, payor guidelines, and clinical documentation requirements.
- Physical and Mental Requirements : Duties of position require intermittent walking, sitting, and standing. Some bending, stooping, and reaching is required with the lifting of items up to a weight of 50 pounds.
