Utilization Review RN in Chicago, IL at Pipeline Health

Date Posted: 1/21/2023

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    Chicago, IL
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    1/21/2023

Job Description



JOB SUMMARY

Is responsible for inpatient and observation patients who have either insurance or public aid.  Is expected to communicate admission information, concurrent reviews and discharge plans and date for this population.  Expectation is to receive authorization for the hospital stay.  This position will enter required information into the Midas system to update all pertinent parties and document authorized days and be responsible to assist with appeals.  Strong communication and organizational skills required.  The Utilization Case Manager is responsible for clinical and documentation aspects of the patient care for t the acute adult related to efficacy and appropriateness of patient care outcomes.



JOB QUALIFICATIONS

1.       Case Management or related field required

2.       Current Illinois Registered Nurse or Licensed Social Worker required.

3.       CPR Certification

4.       Ability to establish and maintain effective working relationships with the public.

5.       Must be able to follow directions and to perform work according to department standards when no directions are given.

6.       Must be emotionally mature and able to function effectively under stress.

7.       Must possess crucial thinking skills, effective written and oral communication skills, strong self-initiative and interpersonal skills.

8.       Previous Case Management or UM Experience recommended.

9.       Experience with Insurance Verification and Pre-authorization preferred.

10.    Knowledge of Admissions and Discharge Criteria for all Insurance Types including Medicare/Medicaid,/Third Party/Commercial.



SUPERVISION

Exercised:  None.  Advises the patient care team of the status of the discharge

Received:  Reports to the Director, Case Management.

JOB RELATIONSHIPS (INTERNAL/EXTERNAL)

Interacts with patients, visitors and representatives from external organizations.  Adjusts patient interaction and to match each patient’s age specific developmental, educational, or other related needs.

JOB DUTIES (* denotes “essential function”)

1.       Demonstrates the WMH Customer Service Values, which are key in providing quality service to patients and customers. *

2.  Assists the Medical Staff in conducting an effective Case Management Program.

3.       Is responsible for inpatient and observation patients who have either insurance or public aid.

4.       Is expected to communicate admission information, concurrent review and discharge plans and date for his population. .

5.       Receives authorization for the hospital stay which could include reviewing the chart for additional information.

6.       Enter required information into the Midas system to update all pertinent parties and document authorized days and be responsible to assist with appeals.

7.       Perform Admission/Ed or CM roles, as required.

8.       Provides necessary assistance to the Utilization Review Committee.

9.       Collects, analyzes, and submits data for presentation to Utilization Review Committee.

10.    Submits reports to appropriate review organizations.

11.    Establishes and maintains criteria for identification and resolution of problems associated with the Case Management/Utilization Review Function.

12.    Prepares status reports as required.

1.       Maintains rapport with physicians, co-workers, representatives of other organization and departments.

2.       Maintains and files appropriate records.

3.       Interprets rules and regulations set by JCAHO, Illinois Department of Health, and other agencies as applicable.

4.       Performs additional assignments and tasks as assigned by management.

5.       Maintains department and corporate LOS and cost per case goals.

6.       Completes all business office status changes.



WORKING CONDITIONS

Physical Environment/Hazards:  Includes walking, standing and sitting. Must be able to do repetitive bending, turning, stooping and lifting. May be exposed to disoriented/combative persons. May be required to be on standby and work extended hours as necessary

OSHA Category II: Normal routine involves no exposure to blood, body fluid or tissue, but exposure or potential for exposure may occur.

TB Exposure: There is an occupational risk for exposure to TB and the incumbent is required to take Particulate Respirator Fit testing.



STATEMENT OF OTHER DUTIES

This document describes the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions.  It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.

All employees are required to familiarize themselves and continually comply with all federal and state healthcare laws, regulations and rules (including Medicare and Medicaid billing requirements which are applicable to the employee’s job duties).  Any employee who becomes aware of possible noncompliance with applicable laws is required to promptly report such possible noncompliance to his or her immediate manager or the compliance Resource Line.  No adverse action or any form of retaliation shall be taken by the Hospital against any employee because of that person’s good faith report of possible noncompliance.