Travel Nurse RN - Utilization Review
Philadelphia, PA
Pyramid Consulting
5x8 hrs, Days

Job Title: Care Management Coordinator/ RN

Location: Remote (candidates must be residing in NJ, PA, DE)

2 roles open, please see the requirements below:

Candidates will need to have UM experience either in Outpatient setting ( PT/OT) or Inpatient setting in bariatric or any surgical elective procedures. (2 submissions needed) 

Candidates must have outpatient experience, chemotherapy, office or infusion center.  Best would be prior auth experience. (1 submission needed)

GENERAL SUMMARY: 

• Under the direction of a designated Care Management and Coordination Supervisor, performs telephonic or onsite review of hospital admissions, determining alternative settings when appropriate.
• Works to add value to healthcare by encouraging efficient and high quality use of the healthcare delivery system.
• Promotes timely and dynamic discharge planning to facilitate early discharge and refers cases to Case Management when indicated.
• Efficiently collaborates with the hospital utilization review department, attending physicians and members/families as appropriate.

DUTIES AND RESPONSIBILITIES:

 

• Performs utilization management for inpatient admissions either onsite or telephonically.
  Using the medical software criteria, establish the need for inpatient, continued stay and length of stay.
• Directs the delivery of care to the most appropriate setting, while maintaining quality.
  Contacts attending physicians regarding treatment plans/plan of care and clarifies medical need for inpatient stay or continued inpatient care
• Identifies inpatient admissions no longer meeting criteria and refers care to plan Medical Directors for evaluation.
• Presents cases to Medical Directors that do not meet established criteria and provides pertinent information regarding members medical condition and the potential home care needs.
• Performs early identification of hospitalized members to evaluate discharge planning needs.
• Collaborates with hospital case management staff, physician and family to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting.
• Identifies and refers cases for case management and disease management.
  Identifies quality of care issues including delays in care. Appropriately refers cases to the Quality
• Management Department and/or Care Management and Coordination Supervisor when indicated.
• Maintains the integrity of the system information by timely, accurate data entry. Utilization decisions are in compliance with state, federal and accreditation regulations.
• Works to build relations with all providers and provides exceptional customer service.
• Reports potential utilization issues or trends to designated supervisor and recommendations for improvement.
• Participates in the process of educating providers on managed care.
• Performs additional related duties as assigned.