The RN of Precertification & Utilization Management is responsible for: - Assessing patient’s clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay
- Evaluating the necessity, appropriateness and efficiency of medical services and procedures provided
- Coordinating and assisting in implementation of plan for members
- Monitoring and coordinating services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate
- Coordinating with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome
- Coordinating the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care
- Monitoring patient’s medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness
- Advocating for the member/family among various sites to coordinate resource utilization and evaluation of services provided
- Encouraging member participation and compliance in the case/disease management program efforts
- Documenting accurately and comprehensively based on the standards of practice and current organization policies
- Interacting and communicating with multidisciplinary teams either telephonically and/or on site striving for continuity and efficiency as the member is managed along the continuum of care
- Understanding fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes
- Evaluating care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes
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