What are the responsibilities and job description for the Utilization Review Nurse position at Siri InfoSolutions, Inc.?
Job Description
Position Title: RN Care Manager
Location: White Plains, NY
Schedule:
- Monday to Friday, 8:30 a.m. - 4:30 p.m. or 9:00 a.m. - 5:00 p.m.
- Monthly weekend rotation (Saturday & Sunday).
Job Type: Full-Time Employee (FTE) with Benefits
Position Summary:
The RN Care Manager is responsible for conducting initial comprehensive assessments for patients upon admission, utilizing established tools to identify high-risk indicators (e.g., AIMS, Geisinger, polypharmacy) to ensure appropriate supportive services and discharge planning. This role involves ongoing reassessment of patient needs throughout their hospital stay, coordination of care, and performing Utilization Review (UR) activities as per departmental policies. The RN Care Manager plays a key role in preventing readmissions and ensuring safe, effective discharge planning.
Essential Functions and Responsibilities:
- Adhere to departmental performance standards, policies, and behaviors.
- Complete a comprehensive initial assessment for all patients.
- Perform multidisciplinary care coordination within the hospital and with external providers.
- Facilitate all transitional planning activities, including:
- Patient and caregiver education.
- Arranging aftercare services.
- Coordinating with commercial payers.
- Addressing high-utilizer patient root causes.
- Communicate and collaborate with appropriate health team members to ensure effective care and discharge planning.
- Contribute to achieving department goals, including:
- Reduction of Length of Stay (LOS).
- Readmission prevention.
- Denial reduction.
- Improving patient satisfaction.
- Document all activities in accordance with department requirements.
- Participate in Performance Improvement initiatives as needed.
- Perform Utilization Review (UR) activities, including:
- Commercial payer reviews.
- Disposition determination.
- Retro/self-audits.
- Medical necessity variances.
- Admission clinical reviews.
- Perform other related duties as assigned.
Education & Experience Requirements:
- BSN or related Bachelor's degree required.
- Minimum of 5 years of clinical experience in ED, critical care, or med/surg required.
- Previous case management experience preferred.
- Knowledge of healthcare financial, regulatory, and payer issues preferred.
- Familiarity with state, local, and federal programs preferred.
- Experience with Milliman/InterQual criteria preferred.
- Registered Nurse (RN) license required.
- PRI/Screen certification preferred.
- Certified Case Manager (CCM) certification preferred.
- Proficient computer skills required.
Core Competencies:
- Strong communication skills, including the ability to establish clear expectations, listen actively, and respond appropriately to ideas and concerns.
- Ability to delegate tasks effectively.
- Ability to remain composed under stress and manage multiple tasks simultaneously.
Physical/Mental Demands & Work Environment:
- Ability to work in environments with exposure to chemicals necessary for performing tasks, with access to the hospital's Safety Data Sheets (SDS).
- Physical ability to walk, stand, and/or sit for extended periods, and carry necessary equipment (e.g., IPad or laptop).
- Ability to perform manipulative tasks requiring arm-hand steadiness and hand-eye coordination.
- Ability to analyze complex problems and prioritize tasks for resolution.
- Visual and auditory abilities to perform job tasks effectively and communicate verbally and in writing.
