Utilization Nurse Care Manager in WHITE PLAINS, New York at White Plains Hospital

White Plains Hospital Job Description

Title:

Utilization Nurse Care Manager

Job Code:

300076

Department/Location:

Care Management

FLSA Status:

Nonexempt

Reports to:

Manager of Care management

Position Summary

The Utilization Nurse Care Manager examines medical treatments and interventions to avoid payment denial and optimizing reimbursements by assessing the treatment’s appropriateness, effectiveness, timing, and setting. The Utilization Nurse Care Manager is responsible for decreasing from payors and ensure the criteria are for the right level of care.

Essential Functions and Responsibilities Includes the Following:

1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors

2. Assures the delivery of quality services in accordance with established hospital, departmental and regulatory/accreditation agency standards.

3. Works collaboratively with multiple disciplines, both internal and external to the organization, in effecting quality and cost-effective management of the patient’s care along the continuum.

4. Conduct pre-certification, continued stay review care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance and applicable criteria, medical policy and member eligibility, benefits, and contracts

5. Maintains a collaborative working relationship with. the payor’s utilization review nurses and case managers and maintains contact with the payor regarding initial assessment, progress, changes in condition, discharge planning, and discharge date as needed.

6. Assures compliance with hospital, nursing department and Human Resources policies and procedures.

7. Maintains knowledge and continuing education related to the operations and needs of the department.

8. Works collaboratively with all members of the interdisciplinary team and promotes team concepts, effective communication, and cooperative spirit, within the department and across departments.9. Demonstrates positive customer service skills, fosters positive and professional attitude with all interactions. 10. Is supportive and actively participates in hospital initiatives and projects. 11. Promotes a positive and professional image at all times and serves as a role model and change agent.12. Has a strong working knowledge of Medicare and Medicaid guidelines and regulatory requirements/parameters, to ensure compliance. Has a strong understanding of HMOs operations and other private health insurances. 13. Performs all other related duties as assigned.

Education & Experience Requirements

Bachelor’s degree in nursing required; master’s degree in nursing preferred.

· NYS RN License required.

· PRI/Screen certification preferred.

· C.C.M. certification preferred.

· Previous experience as a Case Manager required within acute care hospital.

· Knowledge of financial, regulatory and payer issues in a healthcare setting required.

· Knowledge of state, local and federal programs required.

· Experience with Milliman/InterQual criteria required

· Computer skills required

Core Competencies

Attention to detail

Strong communication skills (verbal & written)

Strong knowledge of regulatory requirements

Maintains Composure under stress

.

Physical/Mental Demands/Requirements & Work Environment

• May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital’s SDS (Safety Data Sheet) data base and may be accessed through the hospital’s Intranet site (Employee Tools/SDS Access). A copy of the SDS data base can also be found at the hospital switchboard, saved on a disc.
• The position operates in a professional office environment utilizing standard office equipment such as phones, computers, photocopiers, filing cabinets and fax machines located at multiple locations within the building.
• Ability to constantly greet and direct staff, visitors, and callers.
• Ability to remain stationary for extended periods of time. Ability to move about the office frequently.

Primary Population Served

Check appropriate box(s) below:

☐Neonatal (birth – 28 days)

☐Patients with exceptional communication needs

☐Infant (29 days – less than 1 year)

☐Patients with developmental delays

☐Pediatric (1 – 12 years)

☐Patients at end of life

☐Adolescent (13 – 17 years)

☐Patients under isolation precautions

☐Adult (18 – 64 years)

☐Patients with cultural needs

☐Geriatric (> 65 years)

â˜'All populations

☐Bariatric Patients with weight related comorbidities

☐ Non-patient care population

The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of White Plains Hospital.