Utilization Management (Licensed Social Worker or RN) (On-Site)

Position Summary:

Responsible for the coordination and implementation of case management strategies pursuant to the Case Management process. Plans and coordinates care of the patient from pre-hospitalization through discharge. Responsible for authorization of appropriate services for continued stay and through discharge. Conducts reviews with insurance companies to ensure coverage for patient admissions. Participates in performance improvement activities. Attends 80% of staff meetings. Coordinates care for patient through communication with Physicians, Nurse Practitioners, Clinical Services, Nursing, Assessment and Referrals Department. Attends treatment team meetings as scheduled.

Position Responsibilities:

Clinical / Technical Skills (40% of performance review)

• Reviews intake assessment on patient within 24 hours of admission (patients meeting screening criteria).
• Develops, implements and evaluates individualized patient care plans to meet the needs of patients.
• Reviews care and treatment for appropriateness against screening criteria and for infection prevention and control, quality and risk assessment; documenting same in computerized database.
• Performs follow-up assessments per Case Management Plan and/or department policy.
• Utilizes clinical pathways whenever ordered by physician, to facilitate coordination of patient care.
• Evaluates patient care plans on a regular basis and updates the care plans when needed.
• Plans patient care in collaboration with all members of the healthcare team.
• Consults with other departments, as appropriate, to collaborate in patient care and performance improvement activities. Collaborates with other departments to identify operational problems and develop solutions/resolution.
• Works with all members of the healthcare team to assure a collaborative approach is maintained in care and treatment of the patient.
• Works closely with social worker to integrate psychosocial management of patient/family needs.
• Works with third party payers to validate need for patient care and home care environment needs.
• Reviews patient care activities for occurrences and trends that affect the quality, cost effectiveness and delivery of services. Assures that the outcome of review is appropriately maintained in the computer database.
• Assumes responsibility for timely completion of required case management reports for hospital leadership, regulatory bodies, health plans, insurance carriers, etc.
• Possesses knowledge of Medicare, Medicaid and private insurance providers.
• Assists the Utilization Management Department with all utilization activities as requested and directed.
• Participates in education on and implementation of clinical guidelines and protocols.
• Documentation meets current standards and policies.
• Functions as a patient/family advocate ensuring each patient receives the most cost-effective care possible.
• Maintains optimal continuum of patient care through efficient and effective planning, assessing and coordination of healthcare services.
• Demonstrates an ability to be flexible, organized and function under stressful situations.
• Maintains a good working relationship both within the department and with other departments.
• Remains current on case management th