UCR/Case Management

Duties and Responsibilities:

-Performs perspective review to determine the following

-If insurance coverageand benefits are verified.

-If managed care program requirements are met.5.1.3Care is rendered at the most appropriate level of care.

-Selection of provider is appropriate and within the preferred network if possible.

-Initial length of stay (LOS) is determined if the patient is inpatient

-Determines if appropriate service codes have been selected

-Determines if all investigations, tests, procedures and visits have been captured during the care episode.

-Assessment needs /discharge planning is initiated.

-Performs concurrent review of care episodes while the patient is in the Health Facility to determine the following:

- Accurate patient information is captured in a timely fashion.

- Care continues to be provided at an appropriate level of care and with the appropriateutilization of resources.

-Care is coordinated

-Insurance coverage benefits still match the patient's requirements.

-Financial criteria of discharge screening are met.

-Performs retrospective review of case files to audit care episodes for claims preparation and/or justification and analysis purposes.

-Attend daily meetings to enhance communication between Multidisciplinary purposes.

-Obtain medical justification reports and other related documents required to enhance the approval process.

-Collaborate with the multidisciplinary team in the identification of financial issues related to the treatment plan and the solving of these issues.

-Responsible for the disseminating of any financial data to the multidisciplinary team within the service that they are allocated to.

-Participate in continuous quality improvement through interdisciplinary team measurement, assessment and improvement of patient care delivery processes and services resulting in enhanced quality and appropriate resource management.

-Collaborate with all members of the utilization and Clinical Review Department to enhance all aspects of the resource utilization management program.

-Provide personalized coordinated care, support and treatment for patients and families.

-Treat people with dignity, compassion, and respect.

-Involve patients,familiesand caregivers by providing them with education and resources for offering optimal support to promote recovery.

-Ensures confidentiality of all patient records and derived data.

-Attends mandatory ASH orientation programs and participate in the Departmental orientation and in-service training programs

-Performs any other tasks and duties appropriate to his / her.

-realm of knowledge, skills and experience, as required by the Department Head

QUALIFICATIONS:

Nursing Degree or Diploma from a recognized School of Nursing or College Degree in a related healthcare field

PROFESSIONAL EXPERIENCE:

-Minimum of Three (3) years experience in a large hospital or health management organization (HMO) with demonstrated clinical and administrative skills.

-Familiarity with application of insurance industry standards, preferably in a managed care setting.Minimum of 2 years practical experience in Direct care service.

SPECIALIZED SKILLS:

-Understanding of coding mythologies such as ICD-10 DRG and CPT.

-Well experienced with hospital information systems and personal computer software programs.

-Extensive knowledge of surgical procedures.

-Fluent in written and spoken English