Job Summary

The RN Case Manager and Utilization Review Specialist will collaborate with the Associate Case Manager in assessing, planning, implementing, coordinating, monitoring, and evaluating available health care resources under the health plan for the management of chronic diseases and complex medical conditions, as well as for the promotion of health and prevention of disease. The RN reviews treatment plans and services already underway to ensure the efficient use of utilization systems and the delivery of high-quality care using appropriate medical resources. The role also includes evaluating the quality of care and its alignment with organizational policies, procedures, and guidelines, as well as compliance with government regulations.Referrals are initiated by the Associate Case Manager when patient identifiers are met. A care plan will be created by the RN Case Manager based on the patient’s insurance eligibility, medical necessity guidelines (when applicable), and appropriateness of services. A patient will be considered discharged when care plan goal(s) have been met or a new care plan is established.

Essential Duties and Responsibilities

Case Management

• The clinical functions of an RN Case Manager include but are not limited to:
  o Disease-oriented assessment and monitoring
  o Medication adjustment
  o Health education
  o vSelf-care instructions
• Assesses the physical, functional, social, psychological, environmental, and financial needs of patients. Identifies a cost-effective, comprehensive plan to meet service needs and implements the plan.
• Provides referrals to appropriate community resources. Facilitates access and communication when multiple services are involved; monitors activities to ensure that services are delivered effectively and meet the patients' needs while avoiding duplication.
• Evaluates the patient’s formal and informal support systems.
• Monitors the patient’s progress toward goal achievement and periodically reassesses changes in health status.
• Monitors care plans to ensure the effectiveness and appropriateness of services provided.
• Acts as a patient advocate. Identifies and develops new community resources; assists with problem-solving.
• Assists in referrals for appropriate medical, nursing, or other healthcare services in the home or clinic setting as needed.
• Maintains accurate and confidential patient records.
• Manages referrals under Case Management when any of the following patient identifiers are met:
  o Readmission to the hospital within 30 days
  o Diagnosis of one or more complex medical illnesses:
    ▪ Older adults with chronic diseases
    ▪ Frail elderly
    ▪ Dementia
    ▪ Congestive heart failure
    ▪ Diabetes mellitus
    ▪ Cancer
    ▪ Serious chronic infections
    ▪ High-risk pregnancy
• Manages internal referrals from the Associate Case Manager.
• Documents cases in the system under the Case Management Module.
• Conducts surveys and prepares reports to measure outcomes and evaluate the effectiveness of the program.
• Performs other duties as assigned.

Utilization Review

• Reviews and analyzes medical information telephonically or on-site to determine the medical necessity of continued stay, according to review standards. Further analyzes whether treatments are consistent with patients’ diagnoses.
• Determines medical necessity and length of stay using decision-support systems, identifies discharge goals, and communicates decisions to providers and patients.
• Initiates and coordinates discharge planning with physicians, members, families, caregivers, and ancillary providers to support continuity of care and ensure compliance with approved admission periods.
• Develops improvement action plans as appropriate.
• Provides benefit education to members to ensure accurate administration of their health plan coverage.
• Identifies day and cost outliers, prepares documentation, and reports on quality-of-care issues.
• Submits timely and effective reports to the Medical Director, Health Plan Administrator, Medical Management staff, and other health team members.
• Performs on-site and retrospective reviews related to concurrent services, quality-of-care concerns, access, and outcomes.
• Maintains documentation systems to track treatment activities and outcomes for compliance with organizational and regulatory requirements.
• Conducts pre-contractual and other assessments, as well as audits related to quality management, utilization, and claims.
• Ensures that services provided are within plan benefits and contracted provider networks.
• Identifies and refers catastrophically or chronically ill patients to case management as appropriate.
• Coordinates out-of-area and off-island inpatient cases to ensure cost-effective, quality care and monitors patients for return to service area or work.
• Reviews financial and utilization data, prepares benchmark comparisons, and recommends initiatives to improve performance.
• Performs telephonic or on-site reviews under general supervision, including HEDIS and NCQA-related activities.
• Performs other duties as assigned.

Education and Experience

1. Graduate of a bachelor's degree program in a medically related field. RN license required.
2. Minimum of two (2) years of experience with a proven track record in reviewing treatment plans and services to ensure efficient utilization and delivery of quality care. Experience in performing moderate to complex medical management activities including patient coordination and nursing functions. Must be capable of planning, implementing, and evaluating nursing and healthcare programs.
3. Strong interpersonal skills and ability to work well with coworkers, patients, and customers.
4. Demonstrates behavioral sensitivity, maturity, diplomacy, and tact in complex situations,
including interactions with irate customers.
5. Outstanding oral and written communication skills.
6. High ethical standards and strong personal and professional integrity.
7. Basic familiarity with federal and state healthcare laws and regulations.
8. Highly proficient in Microsoft Office and other commonly used business applications.