The Nurse reviewer performs on-site, written or telephonic assessments and utilization review, across the continuum of care for inpatients and outpatients. The Nurse reviewer identifies plans, coordinates, and implements high quality, cost-effective alternatives when appropriate to the patient’s condition. The Nurse reviewer supports physician decision making, working collaboratively with all members of the health care team, the patient, the patient’s family, co-workers, and internal and external customers to achieve optimal patient outcomes. The Nurse reviewer understands and effectively communicates requirements, and follows CCHP and Chinese Community Health Care Association policies and procedures. The Nurse reviewer accurately tracks as well as reports utilization and quality data.
Major Responsibilities and Duties
1. Performs concurrent review to assure appropriateness of admission, continued inpatient/acute rehabilitation/SNF status, and discharge using established Milliman guidelines or industry standards. Optimize quality of care and utilize cost effective standards of practice.
2. Assures appropriate utilization of outpatient resources that maximize the adherence to evidence based guidelines and high standards of quality care.
3. Identifies, coordinates and implements high quality care and appropriate ancillary care by focusing on the continuum of care and patients‘medical needs.
4. Collaborates with facility case managers and physicians to assure their participation and compliance with post discharge arrangements.
5. Collaborates with clinical social services in complex cases seeking assistance to improve the long term care plans for the patient.
6. Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing inpatient and outpatient care.
7. Evaluates all post acute care services and documents information into the UM/ Case management computer system.
8. Initiates decertification or downgrades of inappropriate admissions and inpatient days based on Milliman criteria in collaboration with UM Manager and Medical Director. Delivers written notification to patient or family members and communicates with members of the health care team as required.
9. Regularly communicates with the manager, physician advisor and primary care physician for support, problem resolution and for notification of decertification and appeals.
10. Authorizes requests for services using Milliman clinical guidelines; refers questionable cases to the UM Manager or Medical Director for determination.
11. Collects and reports utilization data and quality information, such as delays in service, possible avoidable days, readmissions, LOS, etc.
12. Participates as part of the care management team works collaboratively with all department staff.
13. Complies with CCHP Compliance Handbook including Code of Ethics andall statues, regulations and guidelines applicable to federal and state programs.Responsibilities include, following the guidelines and reporting suspected violations of any statue, regulations, agreements or guidelines applicable to all healthcare programs.
14. Catastrophic case management as assigned
15. Accepts and performs other duties as assigned.
- Current California RN license
- Bachelor’s degree or equivalent
- Master’s degree preferred
- CCM preferred
- Minimum two years acute inpatient care experienced required
- At least one year recent utilization management, discharge planning or case management experience preferred