Core Job Function:
Consistently applies the utilization review process as required by the Code of Federal Regulations including the use of the Dignity Health designated criteria for primary review. Incorporates into the utilization review process the ability to access and interpret clinical information against the designated review criteria to reach correct admission status determinations. Has the current knowledge of applicable regulations and laws pertaining to the major payers including Medicare, Medicaid, and other payers. Works with the interdisciplinary team to ensure that the care and services provided are medically necessary, delivered efficiently and timely, and at the appropriate level of care to meet payer requirements and established financial/performance benchmarks for the facility and Dignity Health.
- Completes medical necessity utilization reviews and documents those reviews in MIDAS+ within required time frames
- Review every admission and observation order for appropriateness based on InterQual criteria within the required time frames and follows the approved utilization review procedures if the patient status order is not consistent with the medical necessity assessment
- Notifies admissions office of errors/changes in patient data including changes in physician orders/incorrect admission status designation
- Documents insurance authorizations received in Midas
- Coordinates internal and external services to avoid under or over utilization of resources.
- Indicates the working DRG in MIDAS and other tools
- Facilitates or participates in interdisciplinary team meetings
- Reviews record including physician orders and documents admission, concurrent, discharge reviews and retrospective reviews as assigned
- Communicates with physicians regarding the level of care or admission status when appropriate criteria are not met for inpatient, observation or continued stay
- Refers cases to Physician Adviser according to policy and documents the referral
- Initiates the appropriate letter (HINN: admission or continued stay, ABN) for any Medicare beneficiary if the outcome of the Physician Advisor secondary review indicates that the patient does not meet inpatient admission/observation status or continued stay medical necessity criteria
- Completes, when assigned, the Dignity Health Care Management Rebill Log or other approved communication tools or processes related to billing appropriateness. The log communication includes PFS notification when the outcome of the Physician Advisor secondary review indicates that the patient does not meet admission medical necessity criteria or changes in patient status including the use of Condition Code 44
- All patients presenting to the hospital from ALL points of entry will be assessed for medical necessity, appropriate status and level of care by an RN Case Manager at or before the time of inpatient admission or placement into Outpatient Observation status; payer authorization documented when required
- Points of entry management
- Cross train and provide coverage as needed to GSSJSA transfer center
Mission and Dignity Health Core Values:
Employees will perform their job in a manner consistent with demonstrate the Dignity Health core values of excellence, collaboration, dignity, justice and stewardship.
- Dignity – Demonstrates respect and empathy for each patient’s and family’s privacy and unique needs
- Excellence – Strives to perform at a high level in order to provide excellence in patient care.
- Collaboration – Participates in hospital and / or community-based programs to provide support to those in need.
- Stewardship - Performs daily duties with a responsible utilization of patient, hospital, and community resources
- Justice - Works to ensure support, safety, care, and well being for all patients, families and co-workers, regardless of race, religion, gender, social/economic status or ability.
Professionalism, Quality, Growth and Safety:
Employees will conduct their job functions in a manner consistent with their professional licensure and will demonstrate willingness to learn, improve, grow and achieve.
- Demonstrates responsibility for professional development and growth including identifying continuing education needs and seeking learning opportunities that will enhance job performance and professional satisfaction.
- Effectively organizes work priorities.
- Demonstrates compliance with facility and departmental safety and security policies and practices.
- Educates hospital team members and physicians about the Case Manager role and scope of RN practice.
- Supports the hospital quality, risk and performance improvement programs.
- Keeps informed of local departmental policies and Dignity Health initiatives by attendance staff meetings and Dignity Health sponsored conference calls, meetings and events.
- Demonstrates appropriate attendance per company policy and ensures that unscheduled absences do not exceed the Dignity Health or facility standard.
- Provides proper notification of absences or tardiness within established standards.
- Exhibits interpersonal, collaborative and team building qualities as well as awareness of one’s own behaviors and adjusts behavior and actions appropriately.
- Adheres to all Dignity Health, Human Resources and Compliance Policies and Procedures.