Case Manager/ Utilization Review Registered Nurse

The Utilization Review (UR) Coordinator collaborates with a multidisciplinary team, including physicians, nurses, patient access staff, billing personnel, and external payers, to ensure patients receive the appropriate level of care throughout the continuum of care in an efficient, cost-effective, and quality-focused manner. The UR Coordinator conducts clinical reviews using established medical necessity criteria to support accurate patient status determinations and appropriate resource utilization throughout hospitalization. This role serves as a liaison between the hospital and external payers regarding medical necessity, severity of illness, intensity of service, authorization requirements, and timely utilization of hospital services.

Evaluates patient status using approved medical necessity criteria (MCG and InterQual) to ensure patients receive services at the most appropriate and cost-effective level of care, in collaboration with attending physicians, Physician Advisors, and external payers.

• Monitor patient progression across the continuum of care, intervening to ensure efficient and cost-effective services.
• Collaborates with attending physicians, Physician Advisors, and administrative leadership to determine appropriate patient status and resolve cases that do not meet acute care medical necessity criteria.
• Completes and submits all initial, concurrent, and discharge reviews, including supporting clinical documentation, within payer and Trinity Health established timeframes.
• Facilitates peer-to-peer reviews and escalation processes with payers and Physician Advisors when medical necessity determinations are in question.
• Maintains knowledge of Medicare, Medicaid, commercial payer requirements, and applicable regulations related to medical necessity and utilization management.
• Effectively organize, prioritize, and manage daily assignment caseloads within EPIC Account, Patient and Claim Edit WQs.
• Meets established productivity, quality, timeliness, and documentation standards.
• Responds to payer review requests in accordance with contractual and regulatory requirements.
• Obtains and manages payer authorizations and notifications to support reimbursement and regulatory compliance.
• Assists with utilization management reporting, data collection, and performance improvement initiatives as requested.
• Demonstrates service excellence by providing complete clinical information to government and non-governmental review organizations following HIPAA guidelines.
• Identifies, reviews, and documents Medicare 1 Day stays and Condition Code 44 (CC44) cases in accordance with CMS and organizational requirements.
• Collaborates with onsite staff to ensure timely delivery of required regulatory notices and documentation.
• Serves as a resource for utilization management standards, regulatory requirements, and medical necessity guidelines.
• Participates in denial prevention, denial management, auditing activities, and performance improvement initiatives as assigned.
• Actively manages and resolves concurrent payer denials in collaboration with appropriate stakeholders.
• Accurately document all pertinent communications with providers, provider office staff, payer faxes, clinicals submitted via fax and payer portals, secondary level review discussions with the UR Physician Advisors including the PA determinations, and all patient initial/concurrent criteria reviews completed directly into the hospital's EPIC Electronic Medical Record (EMR) system.
• Participates in related committees as assigned.
• Maintains good rapport and cooperative relationships both internally and externally.
• Addresses conflict professionally and constructively while fostering positive working relationships.
• Identifies opportunities for improvement, recommends solutions, and participates in implementation efforts.
• Maintains professional competency through ongoing education and self-directed learning.
• Maintains a working knowledge of applicable Federal, State and local laws and regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical and professional behavior.
• Safeguard Protected Health Information (PHI) by strictly adhering to the "minimum necessary" standard with external payers to support medical necessity, as well as, strictly adhering to all Trinity policies regarding HIPAA compliance in the workplace, even in the remote office setting.
• Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
• Behaves in accordance with the Mission, Vision, and Values of St. Mary’s Health System.
• Attends team huddles and meetings when working; if unable to attend then review of notes/minutes from meetings is required. Staff are accountable for knowing content of discussions.

Professional Development All Registered Nurses are expected to engage in professional role activities, including leadership, appropriate to their education and position. Registered nurses are accountable for their professional actions to themselves, their healthcare consumers, their peers and to society. The UR Specialist is recognized as an expert in technical skills and professional practice. The UR RN is expected to contribute to the professional growth of others by acting as a preceptor, clinical coach, and mentor.

Required Education, Experience and Certification/Licensure A. Licensure/Certification/Registration: Current GA RN license. BLS required. B.

Education

Must be a graduate of an accredited school of nursing, BSN recommended. C.

Experience

Three to five years related experience and clinically relevant knowledge.

Required Skills and Abilities

• Clinical and analytical skills necessary to facilitate collection of patient clinical information from medical record and to objectively apply various criteria as dictated by exterior payers.
• Proficiency in MCG and INTERQUAL Criteria applications.
• Strong organization and prioritization skills.
• Strong interpersonal and communication skills, including telephonic and electronic.
• Ability to concentrate and pay close attention to detail.
• Computer

Skills

o Required: Basic keyboarding skills

o Preferred

•  EPIC
•  Microsoft Word
•  Microsoft Teams
•  Microsoft Outlook
•  Microsoft Excel

The ideal candidate is highly organized, clinically astute, and comfortable working independently in a remote environment while maintaining strong relationships with providers, payers, and interdisciplinary team members. In addition, is proficient in MCG, InterQual, and EPIC.

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.