Utilization Review Nurse-RN - Main Case Management - Full Time

Job description

To maintain high-quality, medically necessary, evidence-based care, and efficient treatment of all patients, regardless of payment source, by ensuring the patients receive the right care, at the right time, in the right place. Case Management Model: utilize an Integrated Case Management Model. Under this model the Case Managers will follow patients through the continuum while facilitating the functions of utilization review, utilization management, and cost containment. Track and trend denials and payor issues to provide feedback and education to payer relations and the case management department. Clinical review of 100% acute bedded patients admitted to Inpatient or Observation status at The Christ Hospital against medical necessity criteria (Interqual and MCG) for appropriateness of admission. Demonstrate understanding of evidenced based medical necessity criteria. Maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions. Identify/facilitate patient status from observation to inpatient as patient clinical condition warrants. Compliance with all Medicare regulatory requirements Work with external payers completing/securing author...