Nurse Utilization Review/Case Manager

Description

Cameron Memorial Community Hospital is a 25-bed, independent, not-for-profit facility that proudly serves Angola and Steuben County as a Top 100 Critical Access Hospital. We’ve been a cornerstone of this community and the surrounding area in northeast Indiana dating back to 1926. Over the years, we have helped generation after generation of area residents enjoy better health and live comfortably. Today, Cameron Hospital has grown into something more than a simple community hospital. Filled with advanced equipment and skilled specialists, Cameron is a modern, high-tech facility that provides advanced diagnostics, a variety of specialties and cutting-edge treatment options that are combined with highly personalized and compassionate care.

DEPARTMENT: Clinical Integration – Documentation

JOB TITLE: Nurse Utilization Review/Case Manager

SHIFT: 80 Hours Bi-Weekly, Primarily Day Shift, Every other weekend.

Job Summary

Collaborates with patients, providers, nurses, social workers, caregivers, payers, and community agencies in assessing, planning, facilitating, and evaluating timely coordination of quality, cost-effective care across the continuum, including patients for the Transitional Care Program. 

Essential Job Functions

•  Assess all needs for referrals to include durable medical equipment, special needs equipment/services, ongoing specialty medical care, and institutional referrals such as transfers to rehabilitative or nursing home care.
• Collaborates with providers, other members of the healthcare team, and community agencies as needed to help facilitate the best discharge plan for the patient.
• Create individualized and comprehensive case management and treatment plans.
• Follow case and quality management processes in compliance with regulatory guidelines and company procedures.
• Collaborates with access management team to provide accurate and complete clinical information to obtain precertification/authorization.
• Conducts admission review for bedded patients for Medicare and Medicaid beneficiaries as well as private insurance members and self-pay patients based on CMS guidelines. 
• Anticipates and reviews denials by payors for lack of medical necessity, inadequate medical information or delay in discharge; also intervening by written appeal to avoid loss of revenue.
• Identifies and records episodes of preventable delays or avoidable days due to failure of progression-of-care processes.

Licenses/Certifications

• Licensed Registered Nurse in the State of Indiana.

  Education

• Bachelor’s degree in nursing or higher. 
• Associate degree Nurse currently enrolled in an accredited bachelor’s program with a      completion date of fewer than 12 months from hire.

Experience

•  Three years of hospital clinical experience.

 Skills/Competencies

• Demonstrates clinical assessment skills, including assessing clients from pre-admission to post-discharge.
• Comply with the Indiana Pre-Admission Screening/PASAAR program manual to complete designee duties as a discharge planner.
• Knowledge of available community resources and external agencies.
• Ensures timely and accurate completion of workload and clinical documentation.
• Strong collaborator with care team colleagues to problem solve regarding appropriate utilization of resources.
• Expert in InterQual Level of Care Criteria knowledge of local and national coverage determinations.
• Proficient professional writing skills for appeal writing.
• Issues notices of non-coverage (insurance and/or Medicare) to patients as necessary
• Arranges physician to physician clinical reviews with insurance company, attending physician to physician advisor as required.

Supervisor Responsibilities

• None