Case Management/Utilization Review RN

Job Description

Job Description

Reviews, ensures, and maintains inpatient medical records concurrently and retroactively for medical necessity and for quality of care / risk management issues. Advises and provides consultation to physicians and staff regarding appropriate and efficient utilization of hospital resources. Facilitates complex case management. Reports pertinent quality improvement (QI) concerns to the supervisor and physician regarding utilization of clinical resources, inappropriate admissions and denials of services by third party payers. Initiates the process to appeal denials and discrepancies on code assignments. Case Management supports the operations of Southwest Health System, by managing discharge planning for patients utilizing an interdisciplinary approach with consideration of maximizing the functional level of patients post hospital care. The Case Management individual facilitates and promotes patient management and utilization review. The Care Management individual is a professional who coordinates with the interdisciplinary team, patient / family on complex aspects of the patients' care and serves as the focal communication point for patients and staff. The Case Management works closely with the providers(s), nurses, and other members of the team internal and external throughout the continuum of care for patients. The Case Management staff works in conjunction with the interdisciplinary team and is accountable for assessing the discharge plan for effective and efficient utilization of resources, meeting established professional and regulatory standards, and who collaborates with the healthcare team and the patient / family to accomplish agreeable outcomes. Case Management uses a proactive approach, acts as a liaison between SHS and external resources for appropriate placement and / or follow up care.

Regulatory / Educational Requirements :

• Graduate of an accredited school of nursing. Associate degree required, Bachelor's degree preferred.
• Current Registered Nurse Licensure, within state of Colorado.
• Current BLS certification.
• One (1) year of work experience in a health care setting working directly with adult, pediatric or geriatric patients. 3-5 years' experience preferred.
• Knowledge of community resources, experience in public / community health preferred.

Language Skills :

Skills :

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