Job Description

This part-time role will work Saturdays from 9am to 5pm.

Job Summary:

This part-time, fully remote position is for a Registered Nurse with experience in utilization review. The nurse will perform telephonic reviews of hospital admissions, recommend alternative levels of care when appropriate, and promote the efficient and high-quality use of the healthcare delivery system. The position also supports dynamic discharge planning to facilitate early discharge and refers cases to Case Management when necessary. Collaboration with the hospital utilization review department, attending physicians, and members/families is essential.

Duties and Responsibilities:

• Conduct telephonic utilization management for inpatient admissions.
• Use medical software criteria to assess the need for inpatient care, continued stay, and length of stay.
• Ensure care is delivered in the most appropriate setting while maintaining quality standards.
• Contact attending physicians to discuss treatment plans and clarify the medical need for inpatient care.
• Identify inpatient admissions that no longer meet criteria and refer to Medical Directors for evaluation.
• Present cases to Medical Directors that do not meet established criteria, providing pertinent medical information and potential home care needs.
• Perform early identification of hospitalized members to evaluate discharge planning needs.
• Collaborate with hospital case management staff, physicians, and families to determine appropriate discharge settings and facilitate timely discharge.
• Identify and refer cases for case management and disease management.
• Identify and report quality of care issues, including delays in care, and refer to Quality Management or Care Management and Coordination Supervisor as needed.
• Ensure the integrity of system information with accurate and timely data entry, complying with state, federal, and accreditation regulations.
• Build relationships with providers and deliver exceptional customer service.
• Report potential utilization issues or trends to the designated supervisor and provide recommendations for improvement.
• Participate in educating providers on managed care processes.

Education and Experience:

• Registered Nurse (BSN preferred).
• Minimum of three (3) years of acute care clinical experience in a hospital or other healthcare setting.
• Prior discharge planning and/or utilization management experience is required.

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