HCA, Hospital Corporation of America Case Manager of Utilization Review in Irving, Texas
_Case Manager of Utilization Review_ _PRN_ _Medical City Healthcare Division_ _ _ _Medical City Healthcare is one of the region’s largest, most comprehensive health care providers and includes 14 hospitals, 7 off-campus emergency rooms, more than 50 ambulatory sites, more than 7,000 active physicians and 15,000 employees in the Dallas-Fort Worth area. _ _ _ Utilization Review CM role supports the North Texas Case Management departments in admission and concurrent review adhering to medical necessity and Corporate Compliance guidelines. This virtual role reviews new patient admissions and concurrent using Meditech and other information sources and integrates patient clinical data with the appropriate selection of InterQual (IQ) Criteria. As such travel may be involved to the hospital facilities as needed.
a) Performs admission review and concurrent review to determine the clinical appropriateness and medical necessity of the level of care ordered by the physician by applying Interqual criteria b) Initiates timely initial and concurrent reviews per managed care payers contract c) Maintains current knowledge of regulatory guidelines for Utilization Review d) Demonstrated IT ability to become MIDAS expert and work with Corporate Case Management MIDAS for enhancements for North Texas CM departments. e) Demonstrated ability for process improvement in the design and standardization of workflow related to the admission UR process for standardization across all of NTX. This will also lead to competency/new orientation checklist development. f) Communication with the Case Manager and/or Social Worker as indicated to assure timely intervention for resources, discharge planning, or medical necessity. g) Expedite timely response on cases requiring external physician advisor reviews and/or follow up of cases with status determination after normal business hours. h) Work closely with the Utilization Review Coordinator to assure authorization of days based on clinical data provided i) Provide subject matter expert support for Interqual and Midas to team members in facilities j) Demonstrated ability to mentor members of the team and lead process changes and communicate these changes in a positive growing experience for CM members. k) Ability to work with the Denial Manager and NTX Division Director to initiate change to impact NTX and Corporate goals in the area of denial reduction, LOS opportunities and other metrics as determined l) Demonstrates analytical and critical thinking abilities with pro-active decision making and negotiation skills. m) Excellent communication skills (oral and written) and customer service oriented n) Ability to establish collaborative and effective working relationships. o) Ability to work with data for trends and use of reports. p) Ability to travel to the NTX hospitals approximately 10% of the time on as needed bases. q) Requirement to work late afternoon to evening hour shift and weekends
_Qualifications_ _ _ * RN license or compact license required * BSN required * 1-3 years of case management/utilization review experience * 3-7 years of acute care experience * Willing to become a certified IQ instructor for the NTX and orient new CM in appropriate use of IQ. * Certification in ACM, CCM, or CPUR preferred or willing to obtain within 18 months of hire.
Job: *Case Management
Title: Case Manager of Utilization Review
Location: Texas-Irving-North Texas Division Office
Requisition ID: 26500-99535