TITLE: Utilization Management Nurse
DEPARTMENT: Health Services Department
REPORTS TO: Director, Utilization Management
FLSA: Exempt

Position Summary:
In collaboration with the client physician network and contracted health plans, the Utilization Management Nurse serves as the Health Services Department nurse liaison to the client, pro-actively influencing the appropriate utilization of health care services, while acting as advocate to the patient/family as they receive services throughout the continuum of care. The Utilization Management Nurse performs utilization and case management activities onsite and/or telephonically including inpatient precertification, concurrent and retrospective review; as well as discharge planning. The Utilization Management Nurse provides for the complete, accurate and timely processing of utilization and case management data necessary to provide analysis, trending and reporting to the MCO, client PODS and/or Medical Management Committee, and health plan.

Essential Roles and Responsibilities:
I. Utilization Management
  • Performs pre-authorization, onsite concurrent review, discharge planning and retrospective review of inpatients as stipulated by the guidelines and procedures outlined by the Health Services Department.
  • Assigns an ELOS for all admissions using Milliman Care Guidelines.
  • Collects appropriate clinical information to make a determination of medical necessity for reviewed service based on Milliman Optimum Recovery Guideline and tracks variances.
  • Begins the discharge planning coordination process upon admission or precertification.
  • Coordinates care with the members’ HMO as required.
  • Identifies Institutionalized, ESRD, COB and/or Subrogation cases. Notifies NAMM departments, as appropriate.
  • Contributes to department goals and objectives in containing health care costs through the principles of utilization management.
II. Case Management
  • Promotes alternative care programs and researches available options including costs and appropriateness of patient placement.
  • Maintains an active role in assuring the continuity of care for all inpatients through early discharge planning and working with hospital discharge planners, social workers and the patient’s physician in the early identification of potential home care candidates.
  • Recommends, coordinates and educates providers on alternative care options.
  • Works collaboratively with ancillary providers to execute agreed upon treatment plan. Coordinates with the HMO as applicable.
III. Quality Management
  • Contributes to department goals and objectives in maintaining a high quality medical delivery system through the principles of quality improvement.
  • Collaborates with QI Coordinator to facilitate identification of participants and coordination of services for participants in QI Projects.
  • Identifies and presents potential quality issues to appropriate PHO committees for review and recommendations
IV. Data Management
  • Ensures that all institutionalized patient stays, including retrospective cases and denied cases are completely and accurately recorded and documented in the EZCap system in a timely manner.
  • Collects accurate and timely health care data and adequately documents patient related issues, (precert, concurrent review, alternative care, discharge planning, referrals), provider related issues and appropriate use of codes (ICD-9-CM and CPT Codes).
  • Maintains appropriate logs identified by the Medical Management Department and monitors weekly for quality assurance of data entry accuracy.
  • Prepares and presents Utilization Statistics (i.e., days/1000, referrals, HHC, etc.) to appropriate IPA/PHO committees.
V. Special Activities
  • Works with Provider Relations Representatives by communicating office/provider concerns, needs and expectations.
  • Serves as a liaison for PCP/PCP staff and the Health Plan.
  • Helps organize, manage and lead various committees and meetings like PODS, Patient Care, and others.
  • Performs other duties as requested by the Manager and/or Vice President of the Health Services Department.
Knowledge, Skills, and Abilities (Core Competencies):
  • Communication: Maintains professional and positive interaction with physicians, offices, members and health plan staff. Ability to make presentations to committee of physicians in a clear and concise format, ensuring mutual understanding through discussion, questions and feedback; and presents self in professional appearance.
  • Customer Service: Meets internal and external customer expectations by demonstrating understanding of customer/member needs to ensure effective delivery of a solution, product, or service that best fits their needs.
  • Productivity: Effectively and efficiently uses time and resources to achieve work-related goals, organizing activities according to priority and the need for coordination and cooperation with others. Functions at a high level in fast paced environment. Can manage caseload of 20 patients effectively.
  • Problem Resolution/Decision-Making: Applies considered judgments to make decisions within scope of professional practice and assigned job duties, based on critical analysis and evaluation of the situation, the options, and their implications to elicit a positive outcome. Promotes dialogue to seek resolution of conflicts or problems with others. Seeks and offers solutions to problems.
  • Accountability: Takes responsibility for assigned work, following through to ensure goals are met or exceeded. Takes responsibility for decisions and/or actions in the job.
  • Responsiveness to Change: Demonstrates an openness to new ideas and ways of working; adapts to changing needs and situations; approaches issues with an openness to change and a willingness to pursue different approaches to achieve a positive outcome.
  • Teamwork: Works cooperatively and collaboratively with others, contributes to the “team” in its broadest sense; encourages participation, commitment, and an active contribution from him/herself and others in the pursuit of common goals. Actively seeks ways to apply knowledge and skills to help others.
  • Technical: Proficient key boarding skills. Knowledge of MS office including Word and Excel. Familiarity with use of nationally recognized medical criteria for determining medical necessity. CPT and ICD-9 coding.
Minimum Qualifications Registered Nurse or Licensed Practical Nurse with current license in the state of practice. BS in Nursing or other health related area preferred. Minimum three (3) years of experience in utilization review, quality assurance, discharge planning, or other cost management program required, preferably in managed care. At least three (3) years clinical experience, with strong medical/surgical background preferred.