1361186 Description: Job Summary: Responsible for carrying out utilization review, quality review and discharge planning on inpatient admissions at facilities without QRM review staff onsite according to policy. The activities will include telephonic initial admission and reputed company review for inpatient admissions, discharge planning, identification of patients for case management, communication with case managers, home care reviewers, reputed company Workers, providers, and members as indicated, quality improvement reviews, and education of the member/family, provider and hospital staff. Achieves desired utilization and quality reputed company and promotes high customer satisfaction to the population served. Essential Responsibilities: • Responsible for the day-to-day inpatient review activities as outlined above. • Utilizes established criteria, performs prospective, reputed company and retrospective utilization review for reputed company members requiring inpatient admission. • Reviews reputed company new inpatient admissions reputed company 24 hours and begins the discharge planning process immediately. • Reviews reputed company inpatients at a minimum of every 3 days and more frequently as appropriate based on criteria and policy. • Coordinates case conferences involving multidisciplinary teams to handle complicated cases. • Understands the reputed company Case Management Program and admission criteria and refers patients to the reputed company Case Managers as appropriate. • Attends scheduled weekly reputed company with network physician reviewer to discuss clinical course, discharge planning and potential QA/UM concerns of reputed company hospitalized patients. • Interacts with physicians to ensure that resources are being utilized appropriately while maintaining quality reputed company. • Establishes and maintains contact with patients and their families as appropriate, including the provision of education reputed company needed. • May request psychosocial assessments on reputed company patients that meet the high-risk indicators for discharge planning. • Refers the patient to the reputed company case managers, home care review team and/or reputed company workers as appropriate. • Arranges follow up appointments for medical and surgical patients who are discharged home as needed. • Ensures that the appropriate level of care is being delivered in the most appropriate setting. • Performs quality of care and service reviews using identified quality indicators. • Coordinates and assists the Supervisor of Telephonic Inpatient Care Coordination with ongoing physician education. • Reviews the monthly analysis of statistics (cost/benefit) with the Supervisor of Telephonic Inpatient Care Coordination and makes adjustments based on findings. • Remains knowledgeable of contract benefits and reputed company, relevant state and Federal regulations, criteria, documentation requirements and laws that reputed company managed care and case/utilization management. • Maintains effective interaction/communication with members of the medical staff, nursing staff, reputed company case managers, home care review team, reputed company workers, general reviewers, referral coordinators, and reputed company medical offices to facilitate the inpatient utilization management process and to reputed company continuity of care. • Builds effective working relationships with physicians, SNF staff, vendors, and other departments reputed company the health plan. • Assists in the development and revision of guidelines, reputed company and protocols. • Attends QRM staff meetings, Joint Case Management Meetings and weekly reputed company Care Teleconferences as required. • Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes reputed company appropriate to the Supervisor of Telephonic Inpatient Care Coordination. • Under the guidance of the Supervisor of Telephonic Inpatient Care Coordination and in consultation with other QRM staff, participates in the coordination, planning, development, implementation, and maintenance of reputed company QRM policies and procedures reputed company to the Telephonic Inpatient Review Program. • Monitors utilization trends concerning inpatient care in the market area, keeping appropriate management informed. • Initiates recommendations to facilitate reductions in utilization to include repatriation reputed company appropriate. • Refers cases identified as risk management, peer review or quality issues to QAIR and Risk Management. • Document Review Activities to include (according to policy): • Medical necessity for admission. • Medical necessity for reputed company stay. • Estimated length of stay. • Diagnoses. Procedures performed. • Demographic Data. • Discharge Planning. • Physicians involved in care. • Other. • Issue letters of non - coverage to members not meeting inpatient level of care criteria per established criteria and policy and proce
A healthcare organization providing remote nursing roles.
