We are seeking a dedicated and experienced Utilization Management (UM) RN with NICU experience to join our team. Under the guidance of a designated manager, you will conduct telephonic reviews of hospital admissions, ensuring appropriate levels of care and promoting high-quality healthcare delivery. This role involves collaborating with healthcare providers to facilitate timely discharge planning, recommending alternative levels of care, and ensuring efficient use of resources.
Duties and Responsibilities:
- Perform telephonic utilization management for inpatient admissions, utilizing medical software criteria to determine the need for inpatient care, continued stay, and length of stay.
- Direct the delivery of care to the most appropriate setting, ensuring quality standards are met.
- Communicate with attending physicians to discuss treatment plans and clarify medical necessity for inpatient stays or continued inpatient care.
- Identify cases where inpatient admissions no longer meet criteria and refer them to plan Medical Directors for further evaluation.
- Present cases to Medical Directors that do not meet established criteria, providing pertinent information on the member’s medical condition and potential home care needs.
- Conduct early identification of hospitalized members to evaluate discharge planning needs.
- Collaborate with hospital case management staff, physicians, and family members to determine the best alternative settings for discharge and facilitate a smooth transition.
- Identify cases for case management and disease management referral.
- Report quality of care issues or delays in care, referring appropriate cases to the Quality Management Department and/or Care Management and Coordination Supervisor.
- Ensure accurate and timely data entry, maintaining system integrity while complying with state, federal, and accreditation regulations.
- Build positive relationships with all providers and deliver exceptional customer service.
- Report potential utilization issues or trends to the designated supervisor and suggest process improvements.
- Educate providers on managed care practices as part of the utilization management process.
- Perform other duties as assigned.
Education and Experience:
- Registered Nurse (RN) with a BSN preferred.
- Minimum of 3 years of acute care clinical experience in a hospital or healthcare setting, with prior discharge planning and/or utilization management experience required.
- NICU experience required.
Skills:
- Exceptional verbal and written communication skills at all levels.
- Proficiency in using computerized applications and medical software.
- Strong problem-solving abilities and decision-making skills.
- Highly organized with excellent team management and collaboration abilities.
- A strong team player who thrives in a supportive and dynamic work environment.
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