RN Medical Case Manager- Utilization Review

POSITION: Medical Case Manager, Utilization Review

COMPANY: TRISTAR Managed Care

DEPARTMENT: Case Management 200200

REPORTS TO: Supervisor, TRISTAR Managed Care

STATUS: Exempt

Effective Date: 1/26/2021

Position Summary:

Responsible for performing Worker’s Compensation utilization review which includes prospective, concurrent, expedited and retrospective reviews to determine medical necessity and appropriateness for requested medical care using evidence based criteria. Through the discharge planning process, identify patients who have ongoing case management needs and refer these members to the Case Management team for outreach and follow up.

Essential Duties and Responsibilities:

• Conducts prospective, concurrent, expedited and retrospective utilization management, including inpatient services, outpatient services, surgeries and ancillary service requests.
• Reviews all requests for treatment in accordance with preauthorization criteria
• Evaluate treatment requests and review clinical information received with treatment protocols and guidelines, identify medical necessity and refer to the Medical Director if appropriate within the state jurisdiction timeframes
• Review length of stay for inpatient cases when applicable;
• Arrange alternative care services/discharge planning

• Consult with the Medical Director as needed to review complex cases
• Promote cost effective health care with aligned health provider network

Additional Functions and Responsibilities

• Demonstrates ability to meet administrative requirements, including productivity, time management and Quality Assurance standards
• Maintain minimum billing and established template documentation standards adhering to URAC standards and company policies and procedures
• Reporting billing hours in accordance with case activity and billing practices
• Maintain confidentiality- Knowledge of laws and regulations pertaining to HIPPA and PHI
• Other job duties as assigned

Education:

• Diploma, Associate or Bachelor’s degree in Nursing, Master’s level (or higher) in a Nursing, Health or Human Services field or equivalent related experience preferred
• Current, unrestricted Registered Nurse (RN), Licensed Practical Nurse (LPN). Physical Therapy Assistant (PTA) and or Certified Case Manager (CCM) license required
• CCM, CMCN, CPHUR, CPDM, COHN or CDMS certification preferred

Experience:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

• Three or more years of diverse clinical experience in acute care
• Two or more years of Utilization Review or Managed Care experience, Worker’s Compensation background preferred
• Knowledge of utilization management, quality improvement, discharge planning, and or cost management.
• Ability to solve practical problems and deal with a variety of variables.
• Possess planning, organizing, conflict resolution, negotiating and interpersonal skills.
• Excellent interpersonal skills and excellent organizational skills.
• Ability to set priorities and work independently is essential
• Proficient with Microsoft Office applications including Word, Excel, and Power Point

SPECIAL EQUIPMENT OR CLOTHING:

Professional attire adhering to the Company Dress Code

MENTAL AND PHYSICAL REQUIREMENTS

• 
  MENTAL EFFORT

• Reasoning development:

Follow one- or two-step instructions; routine, repetitive task.

Carry out detail but uninvolved written or verbal instructions; deal with a few concrete variables.

Follow written, verbal, or diagrammatic instructions; several concrete variables.

X Solve practical problems; variety of variables with limited standardization; interpret instructions.

Logical or scientific thinking to solve problems; several abstract and concrete variables.

Wide range of intellectual and practical problems; comprehend most obscure concepts.

• 
  Mathematical development:

Simple additional and subtraction; copying figures, counting, and recording.

Add, subtract, multiply, and divide whole numbers.

X Arithmetic calculations involving fractions, decimals, and percentages.

Arithmetic, algebraic, and geometric calculations.

Advanced mathematical and statistical techniques such as calculus, factor analysis, and probability determination.

Highly complex mathematical and statistical techniques such as calculus, factor analysis, and probability determination; requires theoretical application.

• 
  Language development:

Ability to understand and follow verbal or demonstrated instructions; write identifying information; request supplies verbally or in writing.

Ability to file, post, and mail materials; copy data from one record to another; interview to obtain basic information such as age, occupation, and number of children; guide people and provide basic direction.

Ability to transcribe dictation; make appointments and process mail; write form letters or routine correspondence; interpret written work instructions; interview job applicants.

X Ability to compose original correspondence, follow technical manuals, and have increased contact with people.

Ability to report, write, or edit articles for publication; prepare deeds, contracts or leases, prepare and deliver lectures; interview, counsel, or advise people; evaluate technical data.

• 
  PHYSICAL EFFORT

• Physical activity required to perform the job:

Sedentary work: Exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

X Light work:

• Exerting up to 20 pounds of force occasionally
• Exerting up to 10 pounds frequently
• Exerting a negligible amount of force constantly to move objects

(If the use of arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most of the time, the job is rated for Light Work).

Medium work:

• Exerting up to 50 pounds of force occasionally
• Exerting up to 20 pounds of force frequently
• Exerting up to 10 pounds of force constantly to move objects

Heavy work:

• Exerting up to 100 pounds of force occasionally
• Exerting up to 50 pounds of force frequently
• Exerting up to 20 pounds of force constantly to move objects

Very heavy work:

• Exerting in excess of 100 pounds of force occasionally
• Exerting in excess of 50 pounds of force constantly to move objects
• Exerting in excess of 20 pounds of force constantly to move objects

• Visual requirements necessary to perform the job:

Far vision: clarity of vision at 20 feet or more

X Near vision: clarity of vision at 20 inches or less

X Mid-range vision: clarity of vision at distances of more than 20 inches and less than 20 feet

Depth perception: the ability to judge distance and space relationships, so as to see objects where and as they actually are

Color vision: ability to identify and distinguish colors

Field of vision: ability to observe an area up or down or to the right or left while eyes are fixed on a given point

• PHYSICAL EFFORT (cont.)

FREQUENCY

• 
  Physical activity necessary to perform the job and frequency (e.g., continually, frequently, or occasionally):

Climbing: Ascending or descending ladders, stairs, scaffolding, ramps, poles, and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion.

Balancing: Maintaining body equilibrium to prevent falling when walking, standing, or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount and kind of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.

Stooping: Bending body downward and forward by bending spine at the waist. This factor is important if it occurs to a considerable degree and requires full use of the lower extremities and back muscles.

Kneeling: Bending legs at knee to come to a rest on knee or knees.

Crouching: Bending the body downward and forward by bending legs and spine.

Crawling: Moving about on hands and knees or hands and feet.

Reaching: Extending hand(s) and arm(s) in any direction.

Standing: Particularly for sustained periods of time.

Walking: Moving about on foot to accomplish tasks, particularly for long distances.

Pushing: Using upper extremities top press against something with steady force in order to thrust forward, downward, or outward.

Pulling: Using upper extremities to extent force in order to drag, haul, or tug objects in a sustained motion.

Foot

Motion: Using feet to push pedals.

Lifting: Raising objects from a lower to a higher position or moving objects horizontally from position to position. This factor is important if it occurs to a considerable degree and requires substantial use of the upper extremities and back muscles.

X Fingering: Picking, pinching, typing, or otherwise working with fingers rather than with the whole hand or arm as in handling.

X Grasping: Applying pressure to an object with the fingers and palm.

Frequently

Occasionally

• PHYSICAL EFFORT (cont.)
  

FREQUENCY

X Talking: Expressing or exchanging ideas by means of the spoken word. Those activities in which workers must convey detailed or important spoken instructions to other workers accurately, loudly, or quickly.

X Hearing: Perceiving the nature of sounds with or without correction. Ability to receive detailed information through verbal communication and to make fine discriminations in sound, such as when making find adjustments on machined parts.

Feeling: Perceiving attributes of objects, such as size, shape, temperature, or texture by touching with skin, particularly that of fingertips.

X Repetitive Substantial movements (motions) of the wrists, hands,

Motion: and/or fingers.

Regularly

Regularly

Frequently