Utilization Review Care Manager (LPN)- Care Management in Cookeville, Tennessee at Cookeville Regional Medical Center

The primary responsibility of the LPN Utilization Review Care Manager (URCM) is to review medical records, document medical necessity and prepare concurrent clinical appeals (when appropriate) on medical necessity, level of care, length of stay, and authorization denials for hospitalized patients. The URCM is responsible for applying medical necessity screening criteria for appropriate status determination as well as continued stay reviews to ensure patients continue to meet medical necessity for the stay. URCM will submit clinicals and communicate to payors to ensure payor coverage for the continued stay. The URCM will interface with the Physician Advisor on cases not meeting medical criteria, appropriate level of care, need for Peer to Peer and Condition Code 44. Those in the position will also work in collaboration with Physician Advisor to support policy development, process improvement, and staff education related to clinical denial mitigation.

This position requires effective and efficient communication skills, proper clinical documentation, professional code of conduct and critical strategic planning skills. Daily communication in the form of huddles with the care management team will be required. Attendance at daily Multidisciplinary Rounds would be optimal, to ensure correct patient status and length of stay. An understanding of medical necessity, the severity of illnesses, intensity of service, and care coordination needs are key, as the URCM must integrate clinical knowledge with billing knowledge to review, evaluate, and
assist with the appeal of clinical denials related to the care provided to the hospitalized patient. The URCM collaborates with the Multidisciplinary team to assess and improve the denial management, documentation, and appeals process of such findings. The URCM assists with activities related to the monitoring, interpreting, and appeal of concurrent clinical denials received from third-party payors and ensures accuracy in patient billing. The position is integral to the organization, as successful appeals by the URCM result in preventing denied claims and preserving revenue. Other duties as assigned.

Education:

• Completion of an accredited Nursing program and corresponding licensure in the State of Tennessee - required
• Licensed Registered Nurse in the State of Tennessee - preferred
• Two Years acute care experience in a hospital setting
• One year as a utilization review nurse
• Computer literate: proficiency in InterQual or other hospital approved clinical care guidelines, Microsoft Word, Excel and Power Point required
• Current Knowledge of reimbursement requirements, level of care criteria, SI/IS criteria, GMLOS knowledge, DRGs, InterQual guidelines required
• Demonstrates effective interpersonal and communication skills
• Demonstrates flexibility via an ability to adapt to changing priorities
• Demonstrates good customer relations
• Ability to prioritize assignments and effective time-management skills
• Basic knowledge of clinical and psychosocial aspects of patient care
• Must be detail oriented, flexible, and committed to patient advocacy
• Demonstrates skills in planning, organizing, and managing multiple functions and complex processes
• Excellent verbal and written communication skills required
• Knowledge of basic computer software programs

Experience: Three to five years of health care management. A previous background in Case Management/Utilization Review. Knowledge of accepted Nursing procedures in designated patient populations as acquired through 5 years of clinical experience. Knowledge of accounting, management and statistical principals. Knowledge and understanding of computer programs. . Demonstrates physical capabilities with pressure to meet deadlines and expectations.