ED UTILIZATION REVIEW/CASE MANAGER

WE ARE INSIGHT

At Insight Hospital and Medical Center Chicago, we believe there is a better way to provide quality healthcare while achieving health equity. Our Chicago location looks forward to working closely with our neighbors and residents, to build a full-service community hospital in the Bronzeville area of Chicago; creating a comprehensive plan to increase services and meet community needs. With a growing team that is dedicated to delivering world-class service to everyone we meet, it is our mission to deliver the most compassionate, loving, expert, and impactful care in the world to our patients. Be a part of the Insight Chicago team that provides PATIENT CARE SECOND TO NONE! If you would like to be a part of our future team, please apply now!

Duties and Responsibilities:

• Performs inpatient utilization management activities as determined by the utilization plan, professional standards and requirements of payers:
  • Works collaboratively with physicians and other healthcare team members to effect timely and appropriate patient management on an ongoing basis.
  • Collects data as required to support necessity of admission and continued hospitalization based on department standards.
  • Supports the DRG (Diagnosis Related Group) Assurance Program through data collection and ensures that the DRG worksheets contain complete and accurate information and appropriate DRG assignment.
  • Provides accurate clinical information to payers as required.
  • Resolves system problems impeding diagnostic or treatment progress such as delays in the discharge process.
  • Performs non-acute profiling, collecting data on avoidable days and physician advisor referral codes.
• Assists in the division of Patient Care Services staff in facilitating the safe discharge of patients:
  • Participates in family meetings and care conferences as needed to resolve identified issues.
  • Ensures timely referrals for discharge planning occur and regional/community resources are utilized when available.
  • Refers complex cases to Social Services as indicated.
  • Uses clinical and social work experts as needed to ensure delivery of comprehensive patient services.
  • Ensures the patient’s psychological needs are met through direct intervention or consultation with appropriate discipline.
• Interacts regularly with physicians and other members of the health team to obtain information about the course of care; provides information in return regarding potential denial of reimbursement or inappropriate level of care:
  • Refers cases not meeting criteria in a timely manner to the physician advisor.
  • Determines need for and carries out termination of benefits and level of care changes based upon department procedures and maintaining responsibility for related communication and follow-up.
  • Follows up with Medical Director/Physician Advisor to determine outcome or resolution.
• Central communicator with external and internal customers:
  • Practices, develops and endorses customer services skills in relationships with internal and external customers.
  • Provide continuity of care by using community resources and maintains updated resource manual for the department
  • Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered.
  • Collaborates with multidisciplinary team in facilitating the care of the patients and families within the acute setting and along the healthcare continuum.
  • Attends in-service presentations and completes all mandatory education requirements.
• Additional duties and responsibilities:
  • Maintains a safe patient care environment by identifying potential safety hazards and intervening appropriately.
  • Operates and maintains equipment used in patient care in a safe manner.
  • Understands and follows infection control requirements in the care of patients.
  • Maintains awareness of hospital changes by reading posted notices, attachments to paychecks and attending scheduled staff meetings.
  • Performs all other duties as assigned.

Knowledge, Skills, and Abilities:

• Graduate of an accredited school of nursing required.
• Current RN License in the State of Illinois required.
• Two years of relevant clinical experience preferred.
• Previous utilization management experience preferred.
• Knowledge of Medicare/Medicaid, Managed Care and Commercial insurance review processes preferred.
• Ability to proactively anticipate and coordinate multiple functions to promote an optimal office environment.
• Communicates clearly in written and oral modalities with appropriate grammar and vocabulary.
• Proficient in Microsoft Word and Excel required.
• Ability to provide excellent customer service at all times.

Insight is an equal opportunity employer and values workplace diversity!