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Job Description Summary:
This position assists in development, implementation, and revision of the utilization management program. Monitors adherence to the hospital's utilization review plan to ensure effective and efficient use of hospital services and reviews the appropriateness of hospital admissions and extended hospitals stays. Performs utilization review in accordance with all state and federal mandated regulations. Maintains compliancy with regulation changes affecting utilization management. Monitors adherence to the hospital's utilization review plan to ensure effective and efficient use of hospital services and reviews the appropriateness of hospital admissions and extended hospitals stays. He/She works collaboratively with all interdisciplinary staff internal to OhioHealth and also external organizations to achieve timely, cost efficient and effective management of patient care. Performs utilization review in accordance with all state and federal mandated regulations. Maintains compliancy with regulation changes affecting utilization management.Responsibilities And Duties:
80%Reviews all patients medical records and assigns status following Interqual/mcg guidelines. Obtains and reviews necessary physician orders, medical reports and subsequent treatment plans to conduct review. Monitors observation status and outpatient occupying a bed for medical necessity criteria and communicates with members of the healthcare team to ensure timely orders for appropriate changes in level of care. Refers to designated Physician Advisor those patients not meeting severity of illness and intensity of service for acute care. Performs concurrent review on medical records and participates in interdisciplinary collaboration with professional staff. Communicates with third party payers and sends appropriate clinical information for authorization of hospital stay. Receives and processes requests for appeal of denials. Ensures appropriate and cost effective healthcare services to patients.
20%
Actively participates in development, implementation and ongoing evaluation of the utilization management program. Facilitates and/or develops educational programs and advises physicians and other departments of regulations affecting utilization management, efficient allocation of resources, and appropriate length of stay. Monitors quality and type of services delivered to patients, ensuring management within established parameters. Actively participates in program development and quality improvement process to ensure quality outcomes. Acts as preceptors to new hires.
As a High Reliability Organization (HRO), responsibilities require focus on safety, quality and efficiency in performing job duties.
The job profile provides an overview of responsibilities and duties and is not intended to be an exhaustive list and is subject to change at any time
Minimum Qualifications:
Bachelor's Degree (Required)BLS - Basic Life Support - American Heart Association, CPI - Crisis Prevention Intervention - Crisis Prevention InterventionAdditional Job Description:
Graduate from an accredited Bachelor's of Nursing Program; current State of Ohio RN licensure. (If in the Behavioral Health Department, must have Basic Life support (BLS) and Crisis Prevention Intervention (CPI) obtained with in the first 3 0 days of hire and must remain current. ) of discharge process, utilization management intensity of service, severity of illness criteria; Familiarity with computer technology, and ability to use database and spreadsheets; Excellent written/verbal communication and teaching/training skills; Demonstrated success in achieving or exceeding measurable performance criteria in a job setting. Three or more years of clinical Experience within hospital or payer setting. Case Management Certification within first year. BSN or 15 yrs of nursing experience at OhioHealth.
Work Shift:
EveningScheduled Weekly Hours :
36Department
UM and Care CoordinationJoin us!
... if your passion is to work in a caring environment
... if you believe that learning is a life-long process
... if you strive for excellence and want to be among the best in the healthcare industry
Equal Employment Opportunity
OhioHealth is an equal opportunity employer and fully supports and maintains compliance with all state, federal, and local regulations. OhioHealth does not discriminate against associates or applicants because of race, color, genetic information, religion, sex, sexual orientation, gender identity or expression, age, ancestry, national origin, veteran status, military status, pregnancy, disability, marital status, familial status, or other characteristics protected by law. Equal employment is extended to all person in all aspects of the associate-employer relationship including recruitment, hiring, training, promotion, transfer, compensation, discipline, reduction in staff, termination, assignment of benefits, and any other term or condition of employment
Remote Work Disclaimer:
Positions marked as remote are only eligible for work from Ohio.