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 concurrent review for inpatient admissions, discharge planning, identification of patients for case management, communication with case managers, home care reviewers, Social Workers, providers, and members as indicated, quality improvement reviews, and education of the member/family, provider and hospital staff. Achieves desired utilization and quality outcomes 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, concurrent and retrospective utilization review for all members requiring inpatient admission. Reviews all new inpatient admissions within 24 hours and begins the discharge planning process immediately. Reviews all 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 Complex and Transitional Case Management and Specialty Care Programs and admission criteria and refers patients to the Case Managers and specialty care programs as appropriate. Attends scheduled weekly and daily telephonic rounds with physician reviewer to discuss clinical course, discharge planning and potential QA/UM concerns of all hospitalized patients. Interacts with physicians to ensure that resources are being utilized appropriately while maintaining quality outcomes. Establishes and maintains contact with patients and their families as appropriate, including the provision of education when needed. May request psychosocial assessments on all patients that meet the high risk indicators for discharge planning. Refers the patient to the complex case managers, home care review team and/or social 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 current, relevant state and Federal regulations, criteria, documentation requirements and laws that affect managed care and case/utilization management. Maintains effective interaction/communication with members of the medical staff, nursing staff, complex case managers, home care review team, social workers, general reviewers, referral coordinators, and Kaiser Permanente medical offices to facilitate the inpatient utilization management process and to provide continuity of care. Builds effective working relationships with physicians, SNF staff, vendors, and other departments within the health plan. Assists in the development and revision of guidelines, pathways and protocols. Attends QRM staff meetings, Joint Case Management Meetings and weekly Complex Care Teleconferences as required. Investigates, identifies and reports problems and inefficiencies in existing systems, and recommends changes when 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 all QRM policies and procedures related 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 when 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 continued 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 procedure. Works cross-functionally with other departments in striving to meet organizational goals and objectives. Participates in call rotation to provide case management support after hours and on weekends. Achieves and maintains an understanding of relevant state and federal regulations, criteria, and documentation requirements and laws that affect managed care, home health and case/utilization management. Knowledgeable and compliant with regional personnel policies and procedures. Knowledgeable and compliant with QRM departmental and unit specific policies and procedures. Participates in annual regional and departmental compliance training. Knowledgeable and compliant with Principles of Responsibility. Responsible for assisting the Medical Office Administration, Customer Services and Provider Relations in investigating concerns and issues. Access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform the job. Demonstrates understanding of HIPAA privacy regulations by maintaining confidentiality of Protected Health Information (PHI). Demonstrates doing the right thing and doing things the right way is an underlying premise in all work related activities and is able to identify location of copy of Principles of Responsibility. Develops and maintains an awareness of how to report compliance issues and concerns. Identifies issues of wrong doing and promptly investigates and reports to immediate supervisor or Director of Regional Compliance. Assures an atmosphere and culture for staff to report issues of wrong doing. Other duties as assigned. Experience Basic Qualifications: Three (3) years of clinical nursing. Education B.S. in Nursing or four (4) years directly related experience. High school diploma or GED required. License, Certification, Registration Registered Professional Nurse License (Georgia) required at hire Additional Requirements Working knowledge of all relevant federal, state, local and regulatory requirements, including Medicare. Functional knowledge of computers. Experience in ICD9/CPT4 coding. Preferred Qualifications CCM preferred. Preferred three (3) years of clinical nursing with preferred experience in a complex area such as critical care. Preferred experience with managed care or health care delivery systems. Preferred two (2) years of experience in utilization or case management, discharge planning and quality improvement in a managed care or health care setting preferred. B.S. in Nursing.
