Case Manager/Utilization Review

About Us Saint Anthony Hospital is a mission-driven, community-focused organization where your career can thrive while making a meaningful impact on the health and wellness of families in our neighborhood. We take pride in our diverse workforce and the collaborative spirit that drives our team to deliver exceptional patient care and customer service every day. As part of our ongoing commitment to providing the highest quality healthcare, we are excited to be building a new, state-of-the-art hospital that will serve as the cornerstone of the Focal Point Community Campus. This transformational project reflects our dedication to innovation, health equity, and long-term investment in the communities we serve. Position Summary Assumes responsibility and accountability for the appropriate utilization of facilities and services. Coordinates total care given by interdisciplinary team members and directs them to provide and facilitate optimal health care/discharge planning. Key Responsibilities The Utilization Review nurse will coordinate with denial management on all inpatient's denials and contact the provider as needed. The UM nurse, in collaboration with denial management, will notify provider of P2P arrangements and document in EHR under the insurance tab as appropriate. 10% Coordinates and collaborates with physicians, staff nurses and other health care professionals in the care of patients by: (1) monitoring delivery of care and patient's responses to care during hospitalization. (2) assessing patients' clinical status to revise plans of care. (3) discussing pathways and treatment plans with patients, family and/or significant others. (4) reporting and communicating changes in patient status and plan of care. (5) monitoring abnormal lab results and other diagnostic results and discuss with provider as appropriate. Follow up with ancillary department to ensure testing completion to ensure timely throughput of services. 20% Interventions on barriers related to over/under resource utilization, appropriateness of admission, continued length of stay, appropriate level of care and/or patient care delays. Notifies physician advisor for secondary review and to communicate pain point with hospital providers. 10% Identifies discharge-planning needs in complex cases and coordinates with the attending provider, nursing, and other agencies as appropriate. Documents in EHR Discharge Assessment (24-48 hours after admission) and every 3-days or as appropriate in medical record. 10% Performs admission concurrent and discharge review on assigned patients. Documents using hospital approved UM criteria and contacts physician advisor for secondary review when unable to meet inpatient criteria for secondary review as needed. Communicates and provides updated clinical and medical information and anticipated discharge date to insurance companies and other third-party payors. Performs HSI reviews as appropriate for all Medicaid patients (primary and secondary) that require admission and concurrent certification. The UM nurse will document in EHR under authorization section documenting reviewable and non-reviewable code. The UM nurse will add the TAN number when received by hospital. 20% Serves Medicare observation patients copy of MOON for any case over 18 hours. For any Medicare case downgraded to observation from inpatient status the UR nurse will follow Condition Code 44 process and notify patient and/or family as appropriate and document in the EHR. The Utilization Review nurse will provide copy of second IMM for all Medicare and Medicare Advantage cases and provide copy of signed form to be scanned into EHR. 10% The UR Nurse will utilize the Continuing Care escalation process to the Physician Advisor as indicated. Marginal Functions Performs both essential and marginal job functions in a safe manner as identified by Saint Anthony Hospital and the respective department while adhering to the Hospital's confidentiality norms and standards. Actively and consistently demonstrates the core values of Saint Anthony Hospital in all interactions with others. Assumes responsibility for knowing and maintaining established hospital and departmental objectives, policies/procedures including general sanitation, safety, environmental and infection control standards. Participate in performance activities including problem identification, data collection, solution selection, implementation and evaluation. Also assists in the care and maintenance of departmental equipment and supplies as appropriate. Participate in staff meetings and other in-services, meetings or committees as required. Enhances professional growth and development through participation in educational programs, current literature, in service meetings and workshops that are related to assigned areas of responsibility. Exhibits a thorough knowledge of the growth and developmental needs of all patients, from pediatric to the geriatric populations. Qualifications BSN preferred Licensed as a Registered Nurse in the State of Illinois. Recent clinical experience in a hospital setting, or recent clinical experience. Utilization Review experience preferred Requires excellent observation skills, analytical thinking, problem solving, able to communicate and interact with all levels of professionals, plus good verbal and written communication. Flexible with a working knowledge of excel, word and preferably InterQual criteria Basic Life Support Work Conditions Might require: Eye, face protection, gown, Lab Coat, mask.

Could encounter:

Extreme heat/cold, odor/fumes, dirt/dust, noise, exposure to blood borne pathogens Ability to climb stairs Other Information (if applicable) Equal Opportunity Employment Saint Anthony Hospital is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

Compensation:

$78K-$109K