Inpatient Utilization Management Reviewer


Alameda, CA

What you'll be doing

Perform timely concurrent review of inpatient admission to ensure it meets medical necessity guidelines. Provide weekend coverage, when required, for assigned hospitals to ensure member discharge needs are met. Perform bedside assessment and counseling of members, including discussions of goals and expectations upon discharge or transfer. Use clinical judgment to assess and stratify members for appropriate levels of need and refer member to the case and disease management department, if necessary. Identify patients eligible for hospital discharge or transfer to lower level of care; assist in coordinating discharge planning needs with hospital staff, vendors, etc. as appropriate. Coordinate with admitting, attending, PCP, case manager, social workers and other liaisons regarding the patients acuity level and plan of care. Communicate as needed with the companies medical director to validate patient acuity and plan of care; refer admissions for potential denial to the medical director. Participate in daily or weekly internal client companies grand rounds. Participate in hospital grand rounds when appropriate. Receive, process and review prior authorization requests for facility admissions, home health, durable medical equipment (DME) and out of area services. Perform timely concurrent reviews for patients belonging to delegate medical groups that seek inpatient admission out of the contiguous county. Identify members with medical conditions that may meet California children services (CCS) eligibility and coordinate with the plan CCS specialist for referral. Reconcile daily hospital census reports and face sheets against authorizations. Serve as the primary resource for inquiries and follow-up tasks related to the prior authorizations for the assigned hospital. Coordinate out of area patient transfers. Work closely with the company management or clinical personnel to better understand the reasons for modification, deferral or denial of an authorization request. Support the inpatient UM staff with administrative and clinical tasks as needed, including back-up coverage at hospitals as needed. Provide on call coverage during the weekend when required. Assist the manager, inpatient utilization management in tracking utilization and operational trends at hospitals and implementing solutions. Work with various departments at the company to resolve inquiries into claims, authorizations and eligibility. Establish and leverage relationships with contracted hospitals and providers to ensure the needs of the members are met and policies of the plan are followed. Timely review of inpatient admissions, bedside assessment and discharge planning of members. Coordinate other care management activities. Write, report, administration and analysis. Complete other duties and special projects as assigned.

What your background should be

One year experience in managed care or health care setting preferred. Active California registered RN license. Have a cleared TB test prior to or within seven days of hire. Current CPR and First aid card prior to or within six months of hire is preferred. Frequent use of telephone headset. Frequent verbal and written communication with staff and other business associates by telephone, correspondence or in person. Excellent verbal and written communication skills. Ability to work within guidelines and protocols to achieve decisions independently. Excellent critical thinking and problem solving skills. Ability to work in cooperation with others. Ability to prioritize multiple projects as well as work with others. Working knowledge of managed care. Working knowledge of RVS, CPT ICD-9, ICD-10, and CPT 4. Ability to act as resource to department staff. Knowledge of DME and home health services. Knowledge of ancillary and hospital based services. Current driving license, automobile insurance and car registration required. Must maintain current nursing license. Proficient experience in Windows including current Microsoft Office Suite.

Required Schooling / Training

Masters in social work required.

Who is the client company

The client company is a public, not-for-profit managed care health plan committed to making quality health care services.
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