Case Manager Utilization Review Full Time Days - Desert Regional Medical Center

Desert Regional Medical Center is a 385-bed acute-care hospital classified as a stroke receiving center and level 2 trauma facility with an innovative, patient centered and evidence-based Rehabilitation Services Department. Our compassionate team provides a wide range of inpatient and outpatient services, including acute care rehabilitation, joint replacement & spinal surgery, neurosurgery, ICU, Telemetry, step-down care, skilled nursing, as well as outpatient therapy, hand and lymphedema clinics.

GENERAL DUTIES:

The individual in this position has overall responsibility for overseeing the clinical plan of care to conform to evidence-based practice and regulatory requirements. This position integrates care coordination, utilization management, and discharge planning.

The individual’s responsibilities will include, but not be limited to the following activities:

1. Medical necessity screening
2. Care coordination
3. Discharge planning
4. Facilitating multi-disciplinary patient care conferences
5. Managing concurrent disputes
6. Making the appropriate referrals to other departments (e.g., nutrition, PT/OT/ST)
7. Referring complex social issues to Social Service
8. Communicating with patients and their families about the plan of care
9. Collaborating with physicians, office staff and ancillary departments (e.g., lab, pharmacy)
10. Participating in weekly Complex Case Review
11. Arranging for post –discharge patient education
12. Clear, complete and concise documentation in eCCM
13. Maintaining accuracy of patient demographic and insurance information
14. Identifying and documenting potentially avoidable days
15. Identifying and reporting over and underutilization
16. And other duties as assigned.

Attends hospital workshop led by the Director of Case Management or designee that includes the Tenet Case Management Model, InterQual, Discharge Planning, Utilization Management, and other topics specific to case management. Extended orientation with selected Case Managers may occur.

Information used to perform job: patient data, healthcare staff documentation related to patient care, regulatory and payor requirements

Software used to perform job: eCCM: Clinical data interface, InterQual, Case Management documentation, secure faxing, Avoidable Day tracking, Patient Medical Record and HPF, Hospital specific Clinical Software

Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.