Work whereevery momentmattersEvery day over Hartford HealthCare colleagues come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare network The Greater Manchester Region has approximately employees It includes Manchester Memorial Hospital a bed community hospital Rockville General a campus of Manchester Memorial Hospital a bed facility a large multispecialty provider group and visiting nurse services The Greater Manchester Region serves a region of people in towns POSITION SUMMARYThe Utilization Review Case Manager UR CM works in collaboration with the physician and interdisciplinary team to support the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers The role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care promoting clinical best practice and ensuring all patients receive ldquothe right care at the right time and in the right settingrdquo The UR CM is responsible for preoperative concurrent and retrospective reviews in accordance with the utilization management plan The UM CM ensures the appropriate status and level of care is determined and ensures accurate assessment of medical necessity thus appropriate reimbursement Performs duties in support of ECHN mission to ensure the highest quality of patient care in an economically sound and efficient mannerWork whereevery momentmattersEvery day over Hartford HealthCare colleagues come to work with one thing in common Pride in what we do knowing every moment matters here We invite you to become part of Connecticutrsquos most comprehensive healthcare network The Greater Manchester Region has approximately employees It includes Manchester Memorial Hospital a bed community hospital Rockville General a campus of Manchester Memorial Hospital a bed facility a large multispecialty provider group and visiting nurse services The Greater Manchester Region serves a region of people in towns POSITION SUMMARYThe Utilization Review Case Manager UR CM works in collaboration with the physician and interdisciplinary team to support the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers The role integrates and coordinates utilization management and denial prevention by focusing on identifying and removing unnecessary and redundant care promoting clinical best practice and ensuring all patients receive ldquothe right care at the right time and in the right settingrdquo The UR CM is responsible for preoperative concurrent and retrospective reviews in accordance with the utilization management plan The UM CM ensures the appropriate status and level of care is determined and ensures accurate assessment of medical necessity thus appropriate reimbursement Performs duties in support of ECHN mission to ensure the highest quality of patient care in an economically sound and efficient mannerEDUCATIONCERTIFICATION bull Bachelorrsquos Degree in Nursing or a related field bull Current licensure as an RNEXPERIENCE bull ndash yearsrsquo experience in case management discharge planning andor progression of care in the acute care setting bull Minimum of year Utilization Review experience preferred via industry clinical standards ie InterQual Milliman Care GuidelinesCOMPETENCIES bull Comprehensive knowledge of the health care reimbursement system bull Demonstrated skill in creative problem solving facilitation collaboration coordination and critical thinking bull Excellent demonstrated oral written and communication skills bull Proficiency in the use of work processing and spreadsheet application ESSENTIAL DUTIES and RESPONSIBILITIESDisclaimer Job descriptions are not intended nor should they be construed to be exhaustive lists of all responsibilities skills efforts or working conditions associated with the job They are intended to be accurate reflections of the principal duties and responsibilities of this position These responsibilities and competencies listed below may change from time to time Eastern Connecticut Health Network reserves the right to change or assign other duties and responsibilities to this position bull Conducts concurrent and retrospective reviews utilizing InterQual IQ Milliman Care Guidelines MCG or in accordance with CMS rules and regulations for medical necessity criteria to monitor appropriateness of admissions and continued stays and documents findings based on department policyprocedure refers appropriate cases to Physician Advisor for recommendations bull Ensures order in chartEMR and status coincides with the IQ or MCG review or CMS rules and regulations for appropriate Level of Care and status on all patients through collaboration with Case Manager bull Demonstrates thorough knowledge in the application of medical necessity criteria bull Assess the safest and most efficient care level based on severity of illness comorbidities and complications and the intensity of services being delivered bull Utilizes appropriate payer criteria to provide recommendations to the attending physician bull Communicates payor criteria and issues on a case by case basis with multidisciplinary team and follows up to resolve problems with payors as needed initiates peer to peer when appropriate bull Contacts the attending physician for additional information if the patient does not meet the appropriate medical necessity criteria or in accordance with CMS rules and regulations for continued stay bull Escalates review timely to physician advisor timely for lack of medical necessity andor status discrepancies bull Educates physicians and interdisciplinary team regarding approved criteria practice guidelines level of care length of stay and alternative treatment options bull Supports multi disciplinary strategies to reduce length of stay reduce resource consumption and achieve positive patient outcomes bull Collaborates with multidisciplinary team members to identify and implement strategies to ensure appropriate utilization and achieve positive patient outcomes bull Demonstrates knowledge of target length of stay and GMLOS for diagnosis by actively monitoring length of stay timeframe and implementing measures to achieve targets bull Prevents denials by providing timely clinical reviews to payers for authorization of services provided and completes case review for claim reimbursement bull Reviews outlier cases to determine level of care and clinical appropriateness bull Assists as appropriate in the collection and reporting of financial indicators including length of stay approved denied and avoidable days and resource utilization bull Demonstrates skill in communicating with physicians the necessary documentation to demonstrate medical necessity bull Utilizes data to drive decisions related to utilization management for assigned patients including fiscal and clinical data bull Responsible for yearly re education on industry standard criteria ie InterQualMilliman Care Guidelines bull Collects and analyzes data to provide information regarding system barriers to care delivery patient care outcomes resource trends and patterns bull Advocates for supports and protects the rights of patients Promptly reports any potential compromise of rights to appropriate individual s bull Identifies quality infection control utilization and risk management issues with referrals to appropriate committeepersonnel bull Continuously pursue excellence in meeting the needs and expectation of all customers patients families inter disciplinary team members payors screener liaisons and outside services and agencies We take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving colleagues we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this isyour momentEDUCATIONCERTIFICATION bull Bachelorrsquos Degree in Nursing or a related field bull Current licensure as an RNEXPERIENCE bull ndash yearsrsquo experience in case management discharge planning andor progression of care in the acute care setting bull Minimum of year Utilization Review experience preferred via industry clinical standards ie InterQual Milliman Care GuidelinesCOMPETENCIES bull Comprehensive knowledge of the health care reimbursement system bull Demonstrated skill in creative problem solving facilitation collaboration coordination and critical thinking bull Excellent demonstrated oral written and communication skills bull Proficiency in the use of work processing and spreadsheet application ESSENTIAL DUTIES and RESPONSIBILITIESDisclaimer Job descriptions are not intended nor should they be construed to be exhaustive lists of all responsibilities skills efforts or working conditions associated with the job They are intended to be accurate reflections of the principal duties and responsibilities of this position These responsibilities and competencies listed below may change from time to time Eastern Connecticut Health Network reserves the right to change or assign other duties and responsibilities to this position bull Conducts concurrent and retrospective reviews utilizing InterQual IQ Milliman Care Guidelines MCG or in accordance with CMS rules and regulations for medical necessity criteria to monitor appropriateness of admissions and continued stays and documents findings based on department policyprocedure refers appropriate cases to Physician Advisor for recommendations bull Ensures order in chartEMR and status coincides with the IQ or MCG review or CMS rules and regulations for appropriate Level of Care and status on all patients through collaboration with Case Manager bull Demonstrates thorough knowledge in the application of medical necessity criteria bull Assess the safest and most efficient care level based on severity of illness comorbidities and complications and the intensity of services being delivered bull Utilizes appropriate payer criteria to provide recommendations to the attending physician bull Communicates payor criteria and issues on a case by case basis with multidisciplinary team and follows up to resolve problems with payors as needed initiates peer to peer when appropriate bull Contacts the attending physician for additional information if the patient does not meet the appropriate medical necessity criteria or in accordance with CMS rules and regulations for continued stay bull Escalates review timely to physician advisor timely for lack of medical necessity andor status discrepancies bull Educates physicians and interdisciplinary team regarding approved criteria practice guidelines level of care length of stay and alternative treatment options bull Supports multi disciplinary strategies to reduce length of stay reduce resource consumption and achieve positive patient outcomes bull Collaborates with multidisciplinary team members to identify and implement strategies to ensure appropriate utilization and achieve positive patient outcomes bull Demonstrates knowledge of target length of stay and GMLOS for diagnosis by actively monitoring length of stay timeframe and implementing measures to achieve targets bull Prevents denials by providing timely clinical reviews to payers for authorization of services provided and completes case review for claim reimbursement bull Reviews outlier cases to determine level of care and clinical appropriateness bull Assists as appropriate in the collection and reporting of financial indicators including length of stay approved denied and avoidable days and resource utilization bull Demonstrates skill in communicating with physicians the necessary documentation to demonstrate medical necessity bull Utilizes data to drive decisions related to utilization management for assigned patients including fiscal and clinical data bull Responsible for yearly re education on industry standard criteria ie InterQualMilliman Care Guidelines bull Collects and analyzes data to provide information regarding system barriers to care delivery patient care outcomes resource trends and patterns bull Advocates for supports and protects the rights of patients Promptly reports any potential compromise of rights to appropriate individual s bull Identifies quality infection control utilization and risk management issues with referrals to appropriate committeepersonnel bull Continuously pursue excellence in meeting the needs and expectation of all customers patients families inter disciplinary team members payors screener liaisons and outside services and agencies We take great care of careersWith locations around the state Hartford HealthCare offers exciting opportunities for career development and growth Here you are part of an organization on the cutting edge ndash helping to bring new technologies breakthrough treatments and community education to countless men women and children We know that a thriving organization starts with thriving colleagues we provide a competitive benefits program designed to ensure worklife balance Every moment matters And this isyour moment