The Utilization Review Manager is responsible for the leadership and management of the Utilization Nurses as well as for the collection, aggregation, analysis, and reporting of complex clinical data. The collection of this data will ensure appropriate reimbursement for medical services, satisfy requirements of accrediting organizations, and support clinical improvement activities such as development, implementation, and monitoring of clinical guidelines.
The Utilization Review Manager ...
- Develops and implements the organization’s utilization management plan in accordance with the mission and strategic goals of the organization, federal and state law and regulation, and accreditation standards.
- Develops and implements systems, policies and procedures for prospective, concurrent and retrospective case review, clinical practice guidelines, clinical protocols, and reporting quality of care issues identified during the utilization review process.
- Educates and trains the leadership, staff, and administration as to the utilization management plan and their respective responsibilities relative to the plan.
- Collects, analyzes, and maintains data on the utilization of medical services and resources.
- Prepares and presents quarterly utilization management summaries to the Medical Clinical Improvement Committee (MCLIC), identifying potential areas for improvement.
- Reports quality of care issues identified during the utilization review process according to policy and procedure.
- Reviews each medical record to determine the appropriateness of admissions, procedures, and the necessity of continued hospital stay based on Centers for Medicare and Medicaid Services (CMS) guidelines.
- Performs continuing review on the medical record, identifying the need for on-going hospitalization by reviewing and evaluating the clinical data documented in laboratory reports, radiology reports, and multidisciplinary progress notes.
- Develops a system for monitoring and maintaining assurance that a timely review occurs on all identified third party reimbursement cases.
- Identifies and certifies for billing and hospital utilization review purposes, the acute hospital length of stay authorized for each case.
- Actively participates and/or facilitates selected committees such as Utilization Management.
- In compliance with third party payer requirements, identifies those patients requiring pre-admission, pre-procedure, and continued stay authorizations, and obtains those authorizations necessary for reimbursement.
- Facilitates interaction with Pre-Cert, Same Day Surgery and other service departments as necessary.
- Collaborates with other departments in the development and evaluation of projects affecting discharge planning.
Please be advised that we are only considering nurses with the following:
- Illinois State Registered Nurse License
- Three years or more experience in utilization management
- Management experience
Pathway Medical Staffing - 23 months ago
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