Utilization Management Specialist II
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delaware.
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Summary:
Responsible for the coordination and implementation of case managementstrategies pursuant to the Case Management process.
Plans andcoordinates care of the patient from pre-hospitalization throughdischarge.
Responsible for authorization of appropriate services forcontinued stay and through discharge.
Conducts reviews with insurancecompanies to ensure coverage for patient admissions.
Participates inperformance improvement activities.
Attends 80% of staff meetings.
Coordinates care for patient through communication with Physicians,Nurse Practitioners, Clinical Services, Nursing, Assessment andReferrals Department.
Attends treatment team meetings as scheduled.
Position
Responsibilities:
Clinical / Technical Skills (40% of performance review)Reviews intake assessment on patient within 24 hours of admission(patients meeting screening criteria).
Develops, implements and evaluates individualized patient care plansto meet the needs of patients.
Reviews care and treatment for appropriateness against screeningcriteria and for infection prevention and control, quality and riskassessment; documenting same in computerized database.
Performs follow-up assessments per Case Management Plan and/ordepartment policy.
Utilizes clinical pathways whenever ordered by physician, tofacilitate coordination of patient care.
Evaluates patient care plans on a regular basis and updates the careplans when needed.
Plans patient care in collaboration with all members of thehealthcare team.
Consults with other departments, as appropriate, to collaborate inpatient care and performance improvement activities.
Collaborateswith other departments to identify operational problems and developsolutions/resolution.
Works with all members of the healthcare team to assure acollaborative approach is maintained in care and treatment of thepatient.
Works closely with social worker to integrate psychosocialmanagement of patient/family needs.
Works with third party payers to validate need for patient care andhome care environment needs.
Reviews patient care activities for occurrences and trends thataffect the quality, cost effectiveness and delivery of services.
Assures that the outcome of review is appropriately maintained inthe computer database.
Assumes responsibility for timely completion of required casemanagement reports for hospital leadership, regulatory bodies,health plans, insurance carriers, etc.
Possesses knowledge of Medicare, Medicaid and private insuranceproviders.
Assists the Utilization Management Department with all utilizationactivities as requested and directed.
Participates in education on and implementation of clinicalguidelines and protocols.
Documentation meets current standards and policies.
Functions as a patient/family advocate ensuring each patientreceives the most cost-effective care possible.
Maintains optimal continuum of patient care through efficient andeffective planning, assessing and coordination of healthcareservices.
Demonstrates an ability to be flexible, organized and function understressful situations.
Maintains a good working relationship both within the department andwith other departments.
Remains current on case management theory and practice, psychosocialissues current within the community and the healthcare environment.
Safety (15% of performance review)Strives to create a safe, healing environment for patients andfamily membersFollows all safety rules while on the job.
Reports near misses, as well as errors and accidents promptly.
orrects minor safety hazards.
Communicates with peers and management regarding any hazardsidentified in the workplace.
Attends all required safety programs and understandsresponsibilities related to general, department, and job specificsafety.
Participates in quality projects, as assigned, and supports qualityinitiatives.
Supports and maintains a culture of safety and quality.
Teamwork (15% of performance review)Works well with others in a spirit of teamwork and cooperation.
Responds willingly to colleagues and serves as an active part of thehospital team.
Builds collaborative relationships with patients, families, staff,and physicians.
The ability to retrieve, communicate, and present data andinformation both verbally and in writing as requiredDemonstrates listening skills and the ability to express or exchangeideas by means of the spoken and written word.
Demonstrates adequate skills in all forms of communication.
Adheres to the Standards of BehaviorIntegrity (15% of performance review)Strives to always do the right thing for the patient, coworkers, and thehospitalAdheres to established standards, policies#J-18808-Ljbffr Recommended Skills Active Listening Assessments Case Management Clinical Works Databases Infection Control Estimated Salary: $20 to $28 per hour based on qualifications.
//joblink.
delaware.
gov :
For moreinformation, please see:
https:
//joblink.
delaware.
gov/jobs/1193609 />Position
Summary:
Responsible for the coordination and implementation of case managementstrategies pursuant to the Case Management process.
Plans andcoordinates care of the patient from pre-hospitalization throughdischarge.
Responsible for authorization of appropriate services forcontinued stay and through discharge.
Conducts reviews with insurancecompanies to ensure coverage for patient admissions.
Participates inperformance improvement activities.
Attends 80% of staff meetings.
Coordinates care for patient through communication with Physicians,Nurse Practitioners, Clinical Services, Nursing, Assessment andReferrals Department.
Attends treatment team meetings as scheduled.
Position
Responsibilities:
Clinical / Technical Skills (40% of performance review)Reviews intake assessment on patient within 24 hours of admission(patients meeting screening criteria).
Develops, implements and evaluates individualized patient care plansto meet the needs of patients.
Reviews care and treatment for appropriateness against screeningcriteria and for infection prevention and control, quality and riskassessment; documenting same in computerized database.
Performs follow-up assessments per Case Management Plan and/ordepartment policy.
Utilizes clinical pathways whenever ordered by physician, tofacilitate coordination of patient care.
Evaluates patient care plans on a regular basis and updates the careplans when needed.
Plans patient care in collaboration with all members of thehealthcare team.
Consults with other departments, as appropriate, to collaborate inpatient care and performance improvement activities.
Collaborateswith other departments to identify operational problems and developsolutions/resolution.
Works with all members of the healthcare team to assure acollaborative approach is maintained in care and treatment of thepatient.
Works closely with social worker to integrate psychosocialmanagement of patient/family needs.
Works with third party payers to validate need for patient care andhome care environment needs.
Reviews patient care activities for occurrences and trends thataffect the quality, cost effectiveness and delivery of services.
Assures that the outcome of review is appropriately maintained inthe computer database.
Assumes responsibility for timely completion of required casemanagement reports for hospital leadership, regulatory bodies,health plans, insurance carriers, etc.
Possesses knowledge of Medicare, Medicaid and private insuranceproviders.
Assists the Utilization Management Department with all utilizationactivities as requested and directed.
Participates in education on and implementation of clinicalguidelines and protocols.
Documentation meets current standards and policies.
Functions as a patient/family advocate ensuring each patientreceives the most cost-effective care possible.
Maintains optimal continuum of patient care through efficient andeffective planning, assessing and coordination of healthcareservices.
Demonstrates an ability to be flexible, organized and function understressful situations.
Maintains a good working relationship both within the department andwith other departments.
Remains current on case management theory and practice, psychosocialissues current within the community and the healthcare environment.
Safety (15% of performance review)Strives to create a safe, healing environment for patients andfamily membersFollows all safety rules while on the job.
Reports near misses, as well as errors and accidents promptly.
orrects minor safety hazards.
Communicates with peers and management regarding any hazardsidentified in the workplace.
Attends all required safety programs and understandsresponsibilities related to general, department, and job specificsafety.
Participates in quality projects, as assigned, and supports qualityinitiatives.
Supports and maintains a culture of safety and quality.
Teamwork (15% of performance review)Works well with others in a spirit of teamwork and cooperation.
Responds willingly to colleagues and serves as an active part of thehospital team.
Builds collaborative relationships with patients, families, staff,and physicians.
The ability to retrieve, communicate, and present data andinformation both verbally and in writing as requiredDemonstrates listening skills and the ability to express or exchangeideas by means of the spoken and written word.
Demonstrates adequate skills in all forms of communication.
Adheres to the Standards of BehaviorIntegrity (15% of performance review)Strives to always do the right thing for the patient, coworkers, and thehospitalAdheres to established standards, policies#J-18808-Ljbffr Recommended Skills Active Listening Assessments Case Management Clinical Works Databases Infection Control Estimated Salary: $20 to $28 per hour based on qualifications.
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