Utilization Review Case Manager
Company: Waterbury Hospital
Posted on: January 17, 2022
SCOPE OF POSITION:
The Utilization Review Case Manager (UR CM) works in collaboration
with the physician and interdisciplinary team to support the
underlying objective of enhancing the quality of clinical outcomes
and patient satisfaction while managing the cost of care and
providing timely and accurate information to payers. The role
integrates and coordinates utilization management and denial
prevention by focusing on identifying and removing unnecessary and
redundant care, promoting clinical best practice, and ensuring all
patients receive "the right care, at the right time, and in the
right setting". The UR CM is responsible for preoperative,
concurrent, and retrospective reviews in accordance with the
utilization management plan. The UM CM ensures the appropriate
status and level of care is determined and ensures accurate
assessment of medical necessity, thus appropriate reimbursement.
Performs duties in support of ECHN mission to ensure the highest
quality of patient care in an economically sound and efficient
- Conducts concurrent and retrospective review(s) utilizing
InterQual (IQ), Milliman Care Guidelines (MCG), or in accordance
with CMS rules and regulations for medical necessity criteria to
monitor appropriateness of admissions and continued stays, and
documents findings based on department policy/procedure; refers
appropriate cases to Physician Advisor for recommendation(s).
- Ensures order in chart/EMR and status coincides with the IQ or
MCG review or CMS rules and regulations for appropriate Level of
Care and status on all patients through collaboration with Case
- Demonstrates thorough knowledge in the application of medical
- Assess the safest and most efficient care level based on
severity of illness, comorbidities and complications, and the
intensity of services being delivered.
- Utilizes appropriate payer criteria to provide
recommendation(s) to the attending physician
- Communicates payor criteria and issues on a case-by-case basis
with multidisciplinary team and follows up to resolve problems with
payors as needed; initiates peer to peer when appropriate.
- Contacts the attending physician for additional information if
the patient does not meet the appropriate medical necessity
criteria or in accordance with CMS rules and regulations for
- Escalates reviews timely to physician advisor timely for lack
of medical necessity and/or status discrepancies.
- Educates physicians and interdisciplinary team regarding
approved criteria practice guidelines, level of care, length of
stay, and alternative treatment options.
- Supports multi-disciplinary strategies to reduce length of
stay, reduce resource consumption, and achieve positive patient
- Collaborates with multidisciplinary team members to identify
and implement strategies to ensure appropriate utilization and
achieve positive patient outcomes.
- Demonstrates knowledge of target length of stay and GMLOS for
diagnosis by actively monitoring length of stay timeframe and
implementing measures to achieve targets.
- Prevents denials by providing timely clinical reviews to payers
for authorization of services provided and completes case review
for claim reimbursement.
- Reviews outlier cases to determine level of care and clinical
- Assists as appropriate in the collection and reporting of
financial indicators including length of stay, approved, denied,
and avoidable days, and resource utilization.
- Demonstrates skill in communicating with physicians the
necessary documentation to demonstrate medical necessity.
- Utilizes data to drive decisions related to utilization
management for assigned patients, including fiscal and clinical
- Responsible for yearly re-education on industry standard
criteria, i.e., InterQual/Milliman Care Guidelines.
- Collects and analyzes data to provide information regarding
system barriers to care delivery, patient care outcomes, resource
trends and patterns.
- Advocates for, supports and protects the rights of patients.
Promptly reports any potential compromise of rights to appropriate
- Identifies quality, infection control, utilization, and risk
management issues with referrals to appropriate
- Continuously pursue excellence in meeting the needs and
expectation of all customers (patients, families,
inter-disciplinary team members, payors, screener, liaisons and
outside services and agencies.
- Performs all other duties as assigned.
- Bachelor's Degree in Nursing or a related field.
- Current licensure as an RN.
- 2 - 3 years' experience in case management, discharge planning,
and/or progression of care in the acute-care setting.
- Minimum of 1 year Utilization Review experience preferred via
industry clinical standards, i.e., InterQual, Milliman Care
- Comprehensive knowledge of the health care reimbursement
- Demonstrated skill in creative problem solving, facilitation,
collaboration, coordination, and critical thinking.
- Excellent demonstrated oral, written and communication
- Proficiency in the use of work processing and spreadsheet
- Working knowledge of healthcare reimbursement and available
- Must have strong computer skills and the ability to access
internet and other programs applicable to Waterbury Hospital
- Perform automated functions that fall within job
REVISED DATE: 10/21/2021
Location: Waterbury Hospital - Case Management
Schedule: Full Time, Days, 40 hrs Days 8AM- 4:30 PM, inc. 1x a
Keywords: Waterbury Hospital, Waterbury , Utilization Review Case Manager, Executive , Waterbury, Connecticut
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