Under general supervision, the Utilization Review Case Manager (UR CM) performs review of patient referral and medical record for appropriateness for Skilled Home Health services. The UR CM validates the patient’s admission and appropriate visits based on the skilled needs of the patient. The UR CM uses medical necessity based on the Skilled Clinician Start of Care assessment and ongoing needs. The UR CM secures authorization for the patient’s clinical services through collaboration and communic... more details
Description
Under general supervision, the Utilization Review Case Manager (UR CM) performs review of patient referral and medical record for appropriateness for Skilled Home Health services. The UR CM validates the patient’s admission and appropriate visits based on the skilled needs of the patient. The UR CM uses medical necessity based on the Skilled Clinician Start of Care assessment and ongoing needs. The UR CM secures authorization for the patient’s clinical services through collaboration and communication with payers as required. The UR CM provides oversight for the patients continued skilled needs, number of visits and secures authorization from the health plan. The UR CM is a liaison between home health and the health plan.
Core Competencies
Adheres to policies, procedures, and standards of practice to deliver safe and optimal care
Complies with Joint Commission’s national patient safety goals
Complies with organizational quality dashboard/benchmarking goals
Maintains regulatory compliance consistent with quality standards and ethical obligations of the profession
Participates in organizational committees, task forces and/or projects including presentation of project reports, committee recommendations, and task force activities at the unit level
Participates in Peer Review
Participates in professional development activities
Provides age specific and culturally competent discharge planning to all patients.
Department Specific Competencies
Ensures medical necessity of cases by performing daily continued stay reviews on commercial patients as per contract or payer expectation.
Collaborate with revenue cycle team (Physician Advisor, Case Management, Insurance Verification, etc..) to mitigate potential denials.
Accepts referrals from hospitals, physician offices, SNF's and other community referral sources, obtains required orders for services and coordinates infusion products and DME/HME delivery.
Accesses computer system(s) for retrieval of patient information
Acts as a liaison between Healthcare Partners and department on contracting, billing, authorization, claims payment and other issues.
Demonstrates independent judgment, autonomy, initiative, time management and organizational skills and the ability to prioritize projects/functions in a busy work environment.
Acts as a resource for TMIPA, TMPN and TMIP
Education
Degree
Program
Associates
Nursing
Experience
Number of Years Experience
Type of Experience
1
Home Health Experience
Experience with OASIS case management in Home Health
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