Senior Level Utilization Management Specialist Jobs

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The Case Manager RN (U) coordinates the overall interdisciplinary plan of care for patients, from admission to discharge. Monitors care and acts as a liaison between patient/family, healthcare personnel, and insurers. Evaluates the needs of the patient, the resources available, and recommends and facilitates the plan for the best outcome. Develops a discharge plan that provides the best available resources to meet ongoing patient needs and that encourages compliance with medical advice. Identifies patient care issues and suggests revisions to or new clinical pathways to improve quality of care.Care facilitation for all assigned patients including extended recovery, outpatient observation and inpatient admissions to include care progression, timely consultations and testing facilitation , assure social service intervention and individual discharge planning that will include assuring that the transfer or discharge of a patient to another level of care, treatment, services or different setting is always based on the patient’s assessed needs, patient’s insurance coverage benefits and the organizations capabilities to meet these needs.

• Incorporate the fundamental principles of monitoring resource consumption and capture of avoidable days.

• Enter Ancillary notes utilizing the templates for care facilitation.

• Proactive in assuring the orders needed are obtained and facilitates delivery of clinical and community services to patients and families through effective utilization of available resources.

• Attend daily multidisciplinary huddles, meeting facilitation/address progression of care.

• Ensures the appropriateness and cost effectiveness of patient’s plan of care based on DRG.

• Proactively collaborate with physicians(s) to develop patient care plans and review medical needs for continued hospital services and resource consumption.

• Utilize Case Manager nurse driven protocols to facilitate care and request physician orders on items not part of CM nursing protocol.

• Provide all required Medicare documents to the patient and/or proxy when applicable inclusive of the discharge Important Message from Medicare, Code 44 patient notification required documents.

• Process QIO Medicare appeals.

• Acute Care transfers including Psychiatric transfers.

• Attend and facilitate the daily multi-disciplinary huddles.

• Attend and report on assigned LOS 10day outliers-Complex Case Review.

• Communicate to management daily on observation outliers related to care transition and discharge barriers.

• Identifies the patients’ risk factors or obstacles to care, and discharge and readmission risk.

• Evaluates the plan of care regularly by chart review and patient interviews, as well as collaborates with the medical team to facilitate the patients’ movement through the system.

• Educate patients and families on the progression of care.

• Serves as a liaison between patients, families, and healthcare personnel to ensure necessary care is provided promptly, effectively, and in a fiscally responsible manner.

• Promotes quality care to ensure patients receive medically appropriate services in appropriate status and stay standards.

• Facilitates regulatory notifications and patient signatures per policy.

• Maintains knowledge regarding insurance reimbursement policies.

• Relies on experience and judgement to plan and facilitate discharge and transition plans, and assures they meet the physical, social, and emotional needs of the patient.

• Adheres to University and unit-level policies and procedures and safeguards University assets.

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

CORE QUALIFICATIONS

Education:

Bachelor’s Degree in relevant field

Certification and Licensing:

Registered Nurse Licensing (RN)

Experience:

Minimum 7 years of relevant experience

(5 years of case management/utilization review experience)

Knowledge, Skills and Attitudes:

· Ability to communicate effectively in both oral and written form.

· Ability to recognize, analyze, and solve a variety of problems.

· Ability to analyze, organize and prioritize work under pressure while meeting deadlines.

· Ability to maintain effective interpersonal relationships.

The University of Miami offers competitive salaries and a comprehensive benefits package including medical, dental, tuition remission and more.

UHealth-University of Miami Health System, South Florida's only university-based health system, provides leading-edge patient care powered by the ground breaking research and medical education at the Miller School of Medicine. As an academic medical center, we are proud to serve South Florida, Latin America and the Caribbean. Our physicians represent more than 100 specialties and sub-specialties, and have more than one million patient encounters each year. Our tradition of excellence has earned worldwide recognition for outstanding teaching, research and patient care. We're the challenge you've been looking for.

The University of Miami is an Equal Opportunity Employer. Applicants and employees are protected from discrimination based on certain categories protected by Federal law.

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