Reporting to the Utilization Management Manager, supports the Clinical Care Coordinator (C3) role by managing concurrent review, insurance inquiries, prepares documentation for payers. The UM Nurse is responsible for the timely documented concurrent review and pre-bill review as requested; actively supports and participates in the discharge process; schedule follow-up appointments for Level 2 discharges; and participates in the progression of the clinical course of the patient.
1. Bachelor’s Degree in a Healthcare related field and certification in Case Management preferred.
2. Registered Nurse with current licensure to practice nursing in the State of Illinois.
3. Minimum of 2 years of recent applicable Utilization Review/Management experience or equivalent education and/or experience in at least one of the following areas is required: Inpatient Care Delivery, Discharge Planning, or Clinical and Reimbursement Case Management.
4. Knowledge of discharge planning, health care reimbursement, utilization management process, and applicable community resources with the clinical expertise to act as a resource to assigned units.
5. Knowledge of Diagnosis Related Groups (DRGs) and other reimbursement models for their impact on assessment of level of care/use of resources including current knowledge of Medicare, Medicaid and other third party payer reimbursement methodologies.
6. Knowledge of managed care models, financial reimbursement systems, clinical case management processes and utilization management issues.
7. Knowledge of federal, state and other regulatory agency rules & regulations including Illinois Department of Public Health, The Joint Commission, Center for Medicare and Medicaid Services, etc.
8. ACMA or CCM certification within two years of acceptance of position.