Position Summary: 

The Utilization Review Case Manager Nurse role provides a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote patient safety, quality of care and cost of care. Additionally, this role is responsible to the integration of Utilization Review, Risk Management, and Quality Assurance into management in or to ensure use of the facility’s resources with high quality care. This role uses three types of assessments: prospective, concurrent, and retrospective. The position is tasked with the evaluation and implementation of health care plans for individual patients. They are concerned with providing effective and efficient medical care while managing the costs of treatment. A Case Manager Nurse also acts as a liaison between patients, their families, doctors, and health care providers.

Essential Functions:

1. Update and revise patient health care plans.
2. Educate patients and families about health care plans as needed.
3. Make clinical decisions for routine patient care.
4. Accurately document and submit medical records
5. Demonstrate knowledge in medical care; such as diagnostic procedures, medication, symptoms and other treatment related therapies.
6. Provide emotional support to patients and families as needed.
7. Evaluate and determine needs of patients.
8. Implement physician orders and other nursing procedures as needed.
9. Create an environment for open communication.
10. Review patient files or information and check if proper care is being rendered. 
11. Work directly as a lead for the Managed Care Coordinator’s and with insurance companies as a nurse consultant. 
12. Updates and verifies clinical records in patient charts are accurate.
13. Assists with securing referrals and making specialist or test appointments as needed. Knowledge of test requirements, what information the results will provide and the ability to explain thoroughly and clearly, ensuring all questions are answered.
14. Relays messages to and from providers as may be necessary
15. Fills out all patient forms, in a timely fashion, and submits for providers signatures as needed.
16. Participate in grant programs and/or any educational classes provided by clinical.
17. Participate with critical care management and care gaps with patients.
18. Perform frequent case reviews including checking medical records to ensure proper coding and diagnoses are provided within facility and insurance parameters.
19. Speak with providers and patients regarding treatment and open care gaps, and respond to the plan of care.
20. Make recommendations regarding the appropriateness of care for identified diagnoses based on research conditions.
21. Review patient records and insurance open care gaps to prepare paperwork on actions providers can take towards optimal patient care.

Knowledge, Skills, and Abilities:

1. Excellent communication skills; active listening as well as written and oral comprehension/communication skills; Gives full attention to what individuals are saying, understands the point being made, asks appropriate questions to gain better knowledge of situation(s) and repeats information to ensure understanding
2. Excellent customer service skills: actively seeks ways to assist individuals within the scope of assigned duties
3. Good computer skills; Outlook, Windows, Microsoft Office applications; EMR experience required
4. Good time management skills: self-evaluates the use of time and understands how others may be affected
5. Cultural diversity awareness and skills; respects all people regardless of race, nationality, or social standing
6. Ability to multitask; comfortable in a fast-paced environment
7. Ability to work independently (self-motivating) and as a team member
8. Ability to build and maintain effective working relationships with co-workers, providers, managers, patients, and vendors
9. Deductive reasoning and problem-solving skills
10. Problem sensitivity skills; empathetic/understanding
11. Bilingual (Spanish/English) language skills are helpful, but not required

Education, Experience and Licensure:

1. Current and valid Indiana Nursing License (LPN or RN)
2. Current BLS Certified
3. 2-3 years of clinical experience in a medical office or in an acute care setting preferred
4. Apply skills to goal-based projects and disease initiatives

Physical Demands:

1. May sit and/or stand for long periods of time
2. May require full range of body motion including bending, stretching and kneeling or squatting
3. May occasionally be required to lift up to 50 lbs.
4. Must be able to see and hear in normal range with or without correction device(s)
5. Dexterity and hand to eye coordination as normally associated with operating office equipment and computers

Work Environment:

1. Employee is occasionally exposed to fumes or airborne particles, toxins or caustic chemicals, 
2. Potential risk of electrical shock, risk of radiation, and risk of infectious diseases 
3. Fast-paced potentially stressful office environment
4. Noise level in this environment is usually moderate