Utilization Review Manager - Home Care jobs in Colorado
Utilization Review Manager - Home Care ensures quality and level of care for patients are up to established standards and comply with federal, state, and local regulations. Investigates and resolves reports of inappropriate care. Being a Utilization Review Manager - Home Care may require a bachelor's degree. Typically reports to a head of a unit/department. To be a Utilization Review Manager - Home Care typically requires 4 to 7 years of related experience. Contributes to moderately complex aspects of a project. Work is generally independent and collaborative in nature. (Copyright 2024 Salary.com)
Recently Added Utilization Review Manager - Home Care jobs
Case Manager, Utilization Review Registered Nurse - RN
- The Collective Group, LLC
-
Meeker, CO
FULL_TIME
-
RN Case Manager
Reports to: Chief Nursing Officer (CNO)
FLSA Classification: Full-time, Not Exempt, Hourly
Medical Center Case Manager / Discharge Planner / Utilization Review, Registered Nurse (RN) is responsible for compliance with CMS Conditions of Participation including implementation and annual review of the Utilization Management Plan and coordination of the Utilization Management Committee. The Case Manager follows the hospital’s Case Management/Utilization Program that integrates the functions of utilization review, discharge planning, and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated, cost-effective resources. This position provides a collaborative practice to improve quality through coordination of care encompassing length of stay, minimizing cost, and ensuring optimum outcomes.
Essential Functions- Promote the mission, vision, and values of the organization.
- Interview patients to identify their requirements and assess their need for psychosocial, medical, or psychiatric treatment.
- Initiate ongoing communication with the patient and the patient’s family to assess discharge needs starting upon admission.
- Complete assessment for most suitable care plan including but not limited to; transitions/discharge planning needs and risk for readmission.
- Facilitate interdisciplinary team meetings that foster collaboration with the patient, their family and the healthcare team as deemed necessary, this includes multidisciplinary meetings and Utilization Review/Case Management meetings. Provides input in such meetings regarding utilization management and discharge planning.
- Assist in coordinating the activities of all health care professionals responsible for patient needs, to ensure they work toward a common goal.
- Communicate with physicians and providers to ascertain plans for timely discharge.
- Responsible for home care needs being met by the time of discharge, with a goal of arrangements and referrals completed 24 hours prior to discharge with date of discharge is known.
- Runs an effective and efficient Inpatient Interdisciplinary Huddle, assuring that all members of the healthcare team are participating, communicating and working toward a safe and successful discharge.
- Manage and collaborate with the healthcare team to decide if an alternative level of care is appropriate within 24-48 hours, including but not limited to; Admission, Observation, Inpatient, Swing Bed status and complete MDS documentation as necessary.
- Communicates daily with admissions personnel regarding admissions and discharges.
- Assist as needed with obtaining referrals, prior authorizations for Home Health Care, DME, SNF, acute rehab and appointments.
- Provide education and training for healthcare professionals to improve their knowledge of case management techniques and to enhance their skills and knowledge.
- Cooperate with insurance companies, based on information received and document communication and clinical data to third-party payers.
- Review for medical necessity (discuss with admitting provider if medical necessity criteria is met; escalate to Physician Advisor / secondary reviewer as indicated)
- Verify status order and certification.
- Knowledgeable of criteria for Medicare, Medicaid, HMO and private insurance coverage and assessment of the patient’s health insurance plan and work with the insurer and providers to ensure that the best care is delivered with the least financial burden.
- Complete concurrent medical necessity reviews as required or a minimum of every 48 hours for all payers (if appropriate, escalate to secondary reviewer if lack of medical necessity).
- Evaluate IMM, MOON and NOMNC notice delivery process to ensure consistent compliance.
- Issue HINNs as appropriate.
- Ensure that a quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting the data to the appropriate location; reports and identifies data that indicates potential areas for improvement of care and services provided within the system.
- Develop and implement methods, policies and procedures to improve departments’ efficiency and overall effectiveness.
- Review all concurrent denials with Attending for additional information. Refer to secondary reviewer as appropriate.
- Collaborate with peers in Medical Management, Quality Management, Grievance and Appeals.
- Implement and manage effective Utilization Management processes that results in cost efficient utilization of services.
- Reviewing patient records to identify areas where clinical staff can improve skills, documentation, identify patterns in diagnosis and treatment to improve their skills.
- Manage pre-authorization, concurrent review, and retrospective review process for all inpatient, outpatient services.
- Log all secondary reviewer referrals and outcomes.
- Participate in revenue cycle meetings.
- Perform and oversee needs analysis and planning. Work with executive leadership to ensure targets are met for the annual operating plan/financial management.
- Other duties as assigned.
Required Education and Experience- Current, unencumbered nursing license required.
- Minimum of 5 years Nursing Experience in Hospital required.
- Knowledge of Critical Access Hospitals required.
- Knowledge of Swing Bed Programs required.
- Bachelor’s Degree and Master’s Degree preferred.
- Previous experience with word processing and excel preferred.
Skills and Expectations- Kind and professional demeanor.
- Knowledge of nursing services and insurance coverage preferred.
- Strong organizational and interpersonal skills.
- Ability to determine appropriate course of action in more complex situations.
- Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive work attitude.
- Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work.
- Ability to maintain confidentiality of all medical, financial, and legal information.
- Ability to complete work assignments in an accurately and timely manner.
- Communicate positively and effectively, both written and verbally.
- Ability to hand off difficult situations involving patients, physicians, or others in a professional manner.
- Knowledge of the continuum of care and utilization process.
- Ability to document Case Management plans in a clear concise manner.
- Demonstrate effective organizational skills in an evolving environment.
- Work with honesty, compassion and integrity at all times.
- Adherence to ALL procedures and policies.
- Demonstrate a commitment to building and sustaining a diverse, inclusive, and equitable working environment.
Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing this job, the employee:- Must be able to remain in a stationary positon 50% of the time.
- Must be able to move and traverse about the facility 50% of the time.
- Frequently transport objects weighing up to 50lbs
- Occasionally position objects weighing up to 100lbs.
- Must be able to communicate and exchange information in a way others will understand.
- Must be able to recognize details such as color and depth within a few feet of the observer.
- Frequently operates computers, machinery, and other healthcare equipment.
- Constantly positions self to complete essential functions.
- May be required to wear N95s or PAPRs up throughout the shift.
Since 1994, Collective has been providing Recruiting and IT Services to the Health Care Industry. Formed originally from the largest privately held recruiting firm in the US and with over 40 years of industry experience, recruitment is in our DNA. We offer industry leading recruiting services to our clients and an exceptional candidate experience for our applicants.
- 2 Months Ago
Utilization Review Nurse
- Mind Springs Health & West Springs Hospital
-
Grand Junction, CO
FULL_TIME
- Remote Work:This position is eligible to work remotely as approved by managementPosition QualificationsGraduate from an accredited school of Nursing and licensed as a Registered Nurse in the State of ...
- 19 Days Ago
Utilization Review Specialist
- Springstone, Inc.
-
Englewood, CO
FULL_TIME
- Overview Fully On-Site Role Utilization Review Specialist Salary/Hourly: $23- $31.00/hour Denver Springs Summary of Benefits Link Members of our team Enjoy: Working with a highly engaged staff Healthy...
- 20 Days Ago
Utilization Review Specialist
- Denver Springs
-
Englewood, CO
FULL_TIME
- Overview Fully On-Site Role Utilization Review Specialist Salary/Hourly: $23- $31.00/hour Denver Springs Summary of Benefits Link Members of our team Enjoy: Working with a highly engaged staff Healthy...
- 20 Days Ago
Utilization Review Nurse
- COLORADO WEST INC
-
Grand Junction, CO
OTHER
- Job Details Job Location: Psych Hospital - Grand Junction, CO Position Type: Full Time Salary Range: $81,120.00 Salary DescriptionRemote Work: This position is eligible to work remotely as approved by...
- 2 Months Ago
Manager, Care Coordination and Utilization Management
- Physician Health Partners, LLC
-
Denver, CO
FULL_TIME
- Are you looking to work for a company that has been recognized for over a decade as a Top Place to Work? Apply today to become a part of a company that continues to commit to putting our employees fir...
- 1 Month Ago
Utilization Review Manager - Home Care jobs at Popular Companies
Environmental and Utilities Manager
- Leprino Foods
-
Lubbock, TX
- For our future state-of-the art 600+ person Lubbock, TX cheese and whey manufacturing facility, Leprino is seeking an En...
- 6/11/2024 12:00:00 AM
Gas Utilities Manager
- Accenture
-
Austin, TX
- We Are: Our Utility Industry, Transmission & Distribution Practice is powering the progress to a safe, connected, and su...
- 6/10/2024 12:00:00 AM
Director Utilization Management
- Heritage Valley Health System, Inc.
-
Beaver, PA
- Department: Utilization Review. Work Hours: Primarily Monday through Friday, extended hours as needed to support organiz...
- 6/9/2024 12:00:00 AM
Supervisor, Utilization Management
- Centene Corporation
-
Tallahassee, FL
- You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Managem...
- 6/9/2024 12:00:00 AM
Utilization Management Specialist
- Blue Cross and Blue Shield Association
-
Meridian, ID
- Our Utilization Management Rep will coordinate and manage incoming and outgoing correspondence to include referrals, pri...
- 6/9/2024 12:00:00 AM
Director of Utilization Management
- Oceans Healthcare
-
Jackson, MS
- Description The Director Utilization Management is responsible for oversight and management of all utilization review/ca...
- 6/8/2024 12:00:00 AM
Manager, Utilization Management
- Hiring Now!
-
New York, NY
- Creates and upholds policies and procedures for coverage determinations. Serves as subject matter expert for Medicare co...
- 6/8/2024 12:00:00 AM
Director Utilization Management
- Heritage Valley Health System
-
Beaver, PA
- Department: Utilization Review Work Hours: Primarily Monday through Friday, extended hours as needed to support organiza...
- 6/7/2024 12:00:00 AM
About Colorado
Colorado (/ˌkɒləˈrædoʊ, -ˈrɑːdoʊ/ (listen), other variants) is a state of the Western United States encompassing most of the southern Rocky Mountains as well as the northeastern portion of the Colorado Plateau and the western edge of the Great Plains. It is the 8th most extensive and 21st most populous U.S. state. The estimated population of Colorado was 5,695,564 on July 1, 2018, an increase of 13.25% since the 2010 United States Census.
The state was named for the Colorado River, which early Spanish explorers named the Río Colorado for the ruddy silt the river carried from the mountains. The...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Utilization Review Manager - Home Care jobs
$78,114 to $99,583