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INTERVENTIONS - Monitor and evaluate short-term and long-term patient responses to interventions in collaboration with quality assurance and utilization review, maintaining interdependent follow-up as necessary.
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The RN Float Case Manager and Utilization Review Nurse provides coverage for an RN Case Manager or RN Utilization Review Nurse. The RN Float Case Manager and Utilization Review Nurse is assigned to function in the role of either a RN Case Manager or RN Utilization Review Nurse, as provided below.
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When functioning in the role of a RN Utilization Review Nurse: The RN Utilization Management Specialist coordinates communication with admitting financial counselors, case management team, providers, patient financial services, and payers to ensure all services provided by the hospital are authorized by appropriate payer.
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Demonstrates competency in the process of admixture and all infusion and medication preparations; treatments, follow up labs, positive cultures, diagnostic imaging, monitoring system, nurse call system, organ donation and release of remains.
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RN Utilization Review Nurse - Position Accountabilities 25. Provides clinical review to health plans as required by the health plan and/or the Utilization Review plan.
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When appropriate, coordinate and review for medical necessity and appropriate utilization any ancillary professional services, i.e. (home health, infusion, PT, OT, ST, etc. Knowledge of NCQA, CMS, HSAG, and health plan requirements related to utilization management.
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Thorough understanding of managed care systems and utilization review criteria. Recent experience in a hospital, insurance company, or independent review company in utilization, quality review, home care or case management.
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ORDERS AND REFERRALS - Obtain necessary orders from physicians to initiate home health referrals, home infusion medications and supplies, oxygen and equipment; coordinate referrals for oxygen and equipment.
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Conduct initial and ongoing assessments, initiate disease management protocols, determine and manage outcomes, ensure continuity of care through discharge planning, utilization of resources and analysis of variances.
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Department: Utilization Management - UH. IDENTIFICATION - Identify appropriate patients within designated specialty area requiring patient case management interventions by utilizing established procedures including census review, risk screens, and referral.
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