Utilization Review Coordinator/Case Manager
Nursing Administration
Monitors and confirms the necessity of Wilbarger General
Hospital admissions through review of patient records. Serves as liaison between physicians, nursing staff, and discharge planning staff to ensure the most efficient use of WGH resources.
Reviews financial and other data to identify ways to optimize utilization of WGH services.
OSHA Bloodborne Pathogens Class I.
A. Education: Graduate of accredited registered nurse program.
B. Personal Job-Related Skills: Basic understanding of medicine and disease processes as well as WGH functions. Knowledge and abilities in teaching adult education. Effective oral and written communication skills.
Leadership and management skills. Basic computer, data collection, and information evaluation skills.
C. Licensure, Registry or Certification: Registered Nurse currently licensed by the State of Texas Board of Nursing. BLS required. ACLS preferred.
Certification as a Case Manager preferred.
D.
Experience:
1. Prior work experience: At least three years previous experience as a professional Registered Nurse in a health care setting with experience in various phases of clinical nursing practice preferred.
E. Physical and Mental Requirements: Moderate to extended periods of sitting, standing, and walking. Occasional bending, stooping, twisting, reaching, and lifting of patients up to 50 pounds. Occasional heavy lifting when moving or supporting patients who may become weak or helpless.
Revised 09/22/2011

A.
Reviews inpatient and observation patient records on a daily basis for necessity of admission, necessity of continued stay, and meeting of discharge criteria.
B.
Contacts the attending physician for any patients not meeting criteria to determine need for continued hospitalization.
C.
Works with the physician to improve documentation to support medical necessity and clarify what diagnoses were present on admission.
D.
Works directly with physicians, nursing staff, ancillary department staff, and discharge planning staff to develop and implement appropriate discharge plans on a timely basis.
E.
Facilitates the screening of patients for discharge planning needs.
F.
Compiles and analyzes statistical information related to patient admissions, lengths of stay, and profitability to assist in the education of physicians and other WGH staff in proper utilization of WGH services and resources.
G.
Responsible for data collection and chart abstraction of pay for performance measures for submission to regulatory agencies. Will do concurrent review of inpatient records to insure compliance with established data collection standards. Will provide education for nursing staff and physicians regarding compliance with pay for performance standards.
H.
Responds to telephone requests for reviews from insurance companies on a daily basis, determining what information is required and, if necessary, contacting the attending physician for additional information.
I.
Perform random reviews of patients’ records to ensure billing records are supported by medical records to avoid incorrect billing procedures and improve documentation.
J.
Identifies patients in the hospital who may require follow-up after discharge to ensure compliance with appointments or treatment plans.
K.
Contact patient’s attending physician with any identified concerns about patient’s condition or possible referrals for other services.
L.
As necessary, will re-contact any patient that case manager feels may need further follow-up.
Revised 09/22/2011

A.
Maintains confidentiality while working with confidential matters on a daily basis.
B.
Provides service direct to patients while maintaining a positive patient relations atmosphere.
C.
Interacts with patients, family members, Medical Staff members, and other department managers on a continuous basis.
D.
Utilizes aseptic procedures and maintains aseptic precautions when involved in direct patient contact or handling potentially infectious materials.
E.
Provides care appropriate for the neonate and the pediatric, adolescent and geriatric patients served based on demonstrated knowledge of the principles of growth and development over the life span.
F.
Assesses and interprets data on neonate and the pediatric, adolescent and geriatric patients’ status to identify patients’ requirements relative to their age-specific needs and provides care needed as stipulated in departmental policy.
G.
Ensures that licensure and certifications are kept current in accordance
H.
Keeps current with new technology by attending educational offerings and literature reviews. with state laws and hospital policy, and appropriate continuing education is attended for CEU requirements.
STATEMENT OF UNDERSTANDING:
I have read and understand the above JOB DESCRIPTION and understand the essential duties outlined and required in this position. I understand that I should contact my
Department Manager if I have any questions or concerns regarding the job duties and requirements as outlined above. I acknowledge that I have received a copy of this job description.
Employee Signature
Department Manager Signature
Date
Date
Revised 09/22/2011