Case Manager / Utilization Review Nurse

Provides discharge planning and utilization review services in compliance with patient’s discharge planning needs and the hospital’s utilization review program.

Safety Sensitive Position

This position is a designated as “Safety Sensitive Position” under Act 593 of the State of Arkansas. An employee who is under the influence of Marijuana constitutes a threat to patients/customers which Conway Regional is responsible for in providing and supporting the delivery health care related services.

Responsibilities

• Apply clinical knowledge to determine appropriate acuity levels and utilization through chart review.
• Effectively organizes workflow to consistently complete assignments in a timely manner.
• Demonstrates ability to access and effectively utilize primary sources of data.
• Obtains and maintains medical records in conformance with Medical Information policies.

Communicates with co-workers in a manner that is conducive to positive and effective working relationships. Demonstrates respect, honesty and integrity when working with other service providers.

Demonstrates compliance with all relevant hospital, state and federal requirements related to maintenance of confidentiality of persons, data and information systems.

Takes advantage of opportunities made available through CRHS and other professional organizations for continued professional growth and development.

Responsible for analysis of patient information for determination of necessity of admission or continuation of stay.

Review for medical necessity of admission on the first working day after admission using approved review criteria.

Reviews inpatient procedures to determine appropriate utilization and acuity level. Reviews potential for outpatient setting or swing bed utilization.

Reviews all patients for medical necessity of continued stay, or before the next review date, using approved review criteria.

Performs retroactive reviews, as necessary, and responds to the appropriate review agency or third party payor.

Researches denials issued by review agencies and third party payors and responds within the specified time frames for appeal.

Works with others on healthcare team to coordinate for patients discharge needs.

Establishes an effective utilization review process and maintains an active, effective utilization review file system. Recommends, develops and revises policies related to the utilization review process.

Works collaboratively with physicians, Case Management, the discharge planning process, Admissions, Central Scheduling and other CRHS associates.

Educates staff, physicians and other personnel regarding medical necessity requirements as defined by approved review criteria.

Assists with other department functions as assigned.

Qualifications

• Registered Nurse or Licensed Practical Nurse with current, active license to practice in Arkansas, required
• Proof of the highest level of nursing education achieved, required
• At least one-year experience in the area of case management/utilization review, preferred