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Utilization Review Case Manager

Torrance Memorial Medical Center
Torrance, CA Full Time
POSTED ON 2/26/2024 CLOSED ON 4/25/2024

Job Posting for Utilization Review Case Manager at Torrance Memorial Medical Center

Under general supervision, the Utilization Review Case Manager (UR CM) performs review of patient referral and medical record for appropriateness for Skilled Home Health services. The UR CM validates the patient’s admission and appropriate visits based on the skilled needs of the patient. The UR CM uses medical necessity based on the Skilled Clinician Start of Care assessment and ongoing needs. The UR CM secures authorization for the patient’s clinical services through collaboration and communication with payers as required. The UR CM provides oversight for the patients continued skilled needs, number of visits and secures authorization from the health plan. The UR CM is a liaison between home health and the health plan.  

Core Competencies

  • Adheres to policies, procedures, and standards of practice to deliver safe and optimal care

  • Complies with Joint Commission’s national patient safety goals

  • Complies with organizational quality dashboard/benchmarking goals

  • Maintains regulatory compliance consistent with quality standards and ethical obligations of the profession

  • Participates in organizational committees, task forces and/or projects including presentation of project reports, committee recommendations, and task force activities at the unit level

  • Participates in Peer Review

  • Participates in professional development activities
  • Provides age specific and culturally competent discharge planning to all patients.

  

  

Department Specific Competencies

  • Ensures medical necessity of cases by performing daily continued stay reviews on commercial patients as per contract or payer expectation.

  • Collaborate with revenue cycle team (Physician Advisor, Case Management, Insurance Verification, etc..) to mitigate potential denials.

  • Accepts referrals from hospitals, physician offices, SNF's and other community referral sources, obtains required orders for services and coordinates infusion products and DME/HME delivery.

  • Accesses computer system(s) for retrieval of patient information

  • Acts as a liaison between Healthcare Partners and department on contracting, billing, authorization, claims payment and other issues.

  • Demonstrates independent judgment, autonomy, initiative, time management and organizational skills and the ability to prioritize projects/functions in a busy work environment.

  • Acts as a resource for TMIPA, TMPN and TMIP

 

Education

DegreeProgram
AssociatesNursing

  

Experience

Number of Years ExperienceType of Experience
1Home Health Experience

  

Experience with OASIS case management in Home Health  

License / Certification Requirements

Registered Nurse License

Compensation Range 

$53.40 - $82.22 / Hour 

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Salary.com Estimation for Utilization Review Case Manager in Torrance, CA
$101,679 to $133,284
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