• Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents all case management interventions in the current electronic system.
• Monitors and updates accommodation codes and patient types (observation/inpatient), to ensure capture of status and level of care.
• Validates admission and continuing stay criteria with third party payers as well as the Attending Physicians. Recommends alternative care sites where appropriate.
• Updates discharge list for last covered day. Calls discharge date to payer or submit discharge review.
• All concurrent reviews are completed on the first uncovered day unless specified otherwise by the payer.
• Reviews are to include current medical status with supporting labs, study results and treatments which are relevant to the level and acuity of care, procedures, surgeries, plan of care and patient progress towards goal, provide any contributing social, educational or discharge planning issues.
Required Education and Experience
• Required Education: Nursing Diploma
• Required Experience: Minimum of five (5) years' experience as clinical nurse in an acute care setting.
Preferred Education, Experience & Cert/Licenses
• Preferred Education: BSN.
• Preferred Experience: Prior experience as a Case Manager or Utilization Reviewer