DUTIES AND RESPONSIBILITIES:
Minimum of three (3) years of acute care clinical experience in a hospital or other health care setting. Prior discharge planning and/or utilization management experience is desirable.
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.
We are a company committed to creating inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity employer that believes everyone matters. Qualified candidates will receive consideration for employment opportunities without regard to race, religion, sex, age, marital status, national origin, sexual orientation, citizenship status, disability, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to
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Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.