Case Management

Hrs Description: Days ; Duties: Job Summary: Utilization Review Nurse II represents the fully experienced level in utilization review and discharge planning activities.

Job Responsibilities: -Obtains and evaluates medical records for in-patient admissions to determine if required documentation is present. -Obtains appropriate records as required by payor agencies and initiates Physician Advisories as necessary for unwarranted admissions. -Conducts on-going reviews and discusses care changes with attending physicians and others. -Formulates and documents discharge plans. -Provides on-going consultation and coordination with multiple services within the hospital to ensure efficient use of hospital resources. -Identifies pay source problems and provides intervention for appropriate referrals. -Coordinates with admitting office to avoid inappropriate admissions. -Coordinates with clinic areas in scheduling specialized tests with other health care providers, assessing pay source and authorizing payment under Medically Indigent Adult program as necessary. -Reviews and approves surgery schedule to ensure elective procedures are authorized. -Coordinates with correctional facilities to determine appropriate use of elective procedures, durable medical goods and other services. -Answers questions from providers regarding reimbursement, prior authorization and other documentation requirements. -Learns the documentation requirements of payor sources to maximize reimbursement to the hospital. -Keeps informed of patient disease processes and treatment modalities. -Teaches providers the documentation requirements of payor sources to maximize reimbursement to the hospital. -May assist in training Utilization Review Nurse I workers. -Performs other job-related duties as assigned.

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