EPH Registered Nurse (RN) – Utilization Management

Performs telephonic utilization management and associated discharge planning/authorization for AAH delegated risk and ACO members, to ensure appropriate level of care, excellent clinical outcomes, and to optimize the appropriate use of resources in the most cost-effective setting.

Major Responsibilities:

• Responsible for performing telephonic utilization management for network and non-network hospital admissions. Ensures appropriate admissions are to network facilities; works with PCP to redirect admission as indicated by the patient’s condition.
• Facilitates AAH APP and Medical Group members transfer from out of network hospitals to Advocate Hospitals. Utilizes nationally recognized criteria to provide continuous assessment of medical necessity, level of care and medical needs, including identification of AHD (avoidable hospital days). Provides updates to HMOs regarding admission and concurrent medical status of patients when required.
• Works closely with Primary Care Physicians, Hospitalists, Specialists and Medical Directors when necessary to clarify treatment plans and goals. Reviews questionable stays with Medical Director. Coordinates and issues necessary letters, notifications, and documents to comply with AAH and MCO’s utilization and/or denial policy.
• Facilitates safe and timely discharges from the hospital to alternative levels of care (i.e., SNF, home care). Screens all cases for designated quality indicators and reports questionable situations to the manager. Cognizant of all other department duties and functions, such as quality, case management, referrals and provider relations and understands how and when to interface with them.
• Complies with all necessary documentation requirements to meet AAH, MCO, and regulatory agency requirements. Reviews and resolves pended claims issues as needed. Achieves and maintains score >90% on the inter-rater reliability audit. Cognizant of/participates in site specific focus reviews, goals and action plans. Responsible for the coordination, monitoring and authorization of discharge planning from non-network and network hospitalizations to foster efficient cost-effective care and quality outcomes to members in accordance within benefit coverage guidelines.
• Evaluates members’ social, functional status, and health care needs to develop a timely and appropriate discharge plan. Provides member/ family education and emotional support as indicated. Communicates discharge plans to patient, family and/or hospital staff as appropriate. Authorizes contracted vendors for home health, DME and skilled nursing facilities. Assures vendors receive clinical information to provide services efficiently and safely.
• Refers appropriate questions to UM Medical Director regarding cases with unclear medical necessity. Updates and maintains all HMO contract/benefit policies/procedures, preferred provider listing and other pertinent procedures related to UM and referral management. Updates all patient complaint and grievance inquiries with regard to inpatient facility or ancillary providers.
• Coordinates an HMO-contracted provider/vendor for discharge planning referral needs when indicated. Refers complex cases to appropriate case manager for ongoing case management. Communicates and interacts with internal and external providers and administrators in a positive, professional fashion in order to promote the delivery of quality care and effective multi-department/system function.
• Serves as a resource person for contracted physician groups. Provides timely and necessary information to the Inpatient UM analysts to ensure accurate statistics. Participates in hospital meetings necessary to maintain optimal work functions and environment. Updates necessary hospital personnel of approvals, denials, discharge plans. Completes necessary chart documentation.
• Initiates effective and efficient communication with the Attending Physician/PCP/Hospitalist/Specialist to ensure timely and appropriate discharges. Attends necessary meetings with department. Completes necessary paperwork for efficient department operations. Participates in ongoing physician education as appropriate. Interacts with physicians and staff as necessary. Educates hospital personnel, vendors regarding managed care.

Licensure, Registration, and/or Certification Required:

• Registered Nurse license issued by the state in which the team member practices.

Education Required:

• Bachelor's Degree in Nursing.

Experience Required:

• Typically requires 3 years of experience in a clinical role with at least one year of previous utilization review, discharge planning or case management experience.

Knowledge, Skills & Abilities Required:

• Ability to handle multiple tasks.
• Ability to intervene and handle difficult situations.
• Good verbal and written communication skills. Excellent interpersonal communication and problem-solving skills.
• Ability to work independently and prioritize assignments, using independent judgement and discretion.
• Good computer and keyboard proficiency.
• Demonstrated initiative in process improvement recommendations.
• Ability to anticipate potential problems and intervene appropriately.

Physical Requirements and Working Conditions:

• This position requires travel, therefore, will be exposed to weather and road conditions.
• Operates all equipment necessary to perform the job.
• Exposed to a normal office environment.
• Able to handle stress and high workload volumes.
• Flexible with work assignments.
• Ability to be cross trained as necessary.
• Ability to effectively communicate denial of services to members and / or providers.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.