The Christ Hospital Health Network RN Utilization Review - Case Management in CINCINNATI, Ohio

Title: RN Utilization Review - Case Management

Shift: Full Time, Days

Job Overview: 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.

The Utilization Review RN may perform the following duties:

  • 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 authorization for all services provided.

  • Monitors cases for appropriateness of continued stay, level of care and services, and quality of care using approved screening criteria. Communicate with physicians when alternatives to inpatient care are indicated by clinical review.

  • Identify cases needed for second level of review- refers cases to the Physician Advisor that do not meet established guidelines for admission or continued stay.

  • Consistent collaboration with the RN Case Manager to prevent extended length of stays and appropriate status determination.

  • Identifies potential delays in service or treatment and refers to the appropriate individuals within the multidisciplinary patient care teams for action/resolution.

  • Track and trends avoidable day information in Midas per process.

  • Identifies problems related to the quality of patient care and refers such problems to the Performance Improvement Department.

  • Adherence to department productivity standards. Initial, concurrent, and retro reviews should be completed timely including all necessary information for approval of claims. All reviews should contain information only pertinent to IS/SI (Intensity of Service/Severity of Illness).

  • Compliance with documentation methods for monthly reporting and statistics for presentation to the Utilization Review Committee.

  • Interfaces with patient registration and patient financial services etc. to collaborate on financial issues.

  • Establish an effective rapport and relationship with third party payers to promote cost effective clinical outcomes.

  • Assist in denial and appeal process

  • Performs other duties as assigned, including but not limited to:

  • Demonstrates professional responsibility required for a Utilization Review Nurse

  • Complies with department and hospital policies at all times

  • Maintains compliance with State/Federal Guidelines and standards

  • Conforms to all requirements of Medicare

  • Keep current on changing laws and requirements of Medicare

  • Demonstrate a positive attitude at all times

Education:Bachelor’s Degree. Graduate of an accredited school of nursing with current licensure OR actively enrolled in a BSN program with completion date within 3 years of hire date and a graduate of an accredited school of nursing with current licensure.

Years of Experience: 3-5 years of medical/surgical nursing necessary and a minimum of 3 years of utilization review experience required.

Licenses & Certifications: Licensed to practice in the State of Ohio. Certified Case Management (CCM) or Accredited Case Management (ACM) preferred.

There are many ways to define excellence. For us at The Christ Hospital, it’s all about our patients...And making healthcare what they want it to be. Accessible. Personal. Affordable.

Our commitment to exceptional outcomes, affordable care and the finest patient experiences is recognized yearly with numerous awards from leading healthcare organizations and publications. At the top of our list of honors are the 17 consecutive years that we’ve been named to U.S. News & World Report’s list of Best Hospitals and being named the Most Preferred Hospital by the Greater Cincinnati community for 21 consecutive years (National Research Corporation).

What does this mean for you?

GROWTH- opportunities to learn, develop, and impact.

VALUE - a robust employee package that provides you the ability to maintain a healthy work-life balance, competitive compensation, flexible and meaningful benefits, development opportunities so you can be your best self, and a culture of compassion.

PRIDE- from all that we have accomplished in our past, and all that we’re positioned for in the future.

CHALLENGE- we are in one of the most competitive markets in the nation, yet continue to rise to the top through our incredible employees and transformational results. We seek individuals motivated by what it takes to be a part of a winning team.

Named #24 on Forbes 500 America’s Best Employers for 2017, we are transforming care…inspired by you.