Utilization Management/Case Management Nurse

• Counsels with patients and family members in decision making and in meeting the needs of the patient. Maintains knowledge of resources and facilities available to patients and family members.
• Coordinates the discharge planning process ensuring involvement of all members of the healthcare team. Collaborates and consults with physicians on patient’s progress and discharge planning needs.
• Maintains ongoing dialogue with supervisor and other healthcare providers to ensure effective implementation of care plans.
• Performs utilization review ensuring admissions meet criteria for appropriateness of care and medical necessity.
• Collaborates with personnel at other facilities to coordinate smooth and effective patient transfers and transitions of care.
• Applies knowledge of the patient population served; proves age-specific care; applies knowledge of expected norms in planning care. Creates plan for care across the continuum.
• Domestic U.S. travel may be required.
• Compiles, evaluates, and reports statistics to members of the team and utilizes the information to facilitate process improvement.
• Monitors patient care by performing continuous assessments and evaluations to ensure patient is progressing towards desired outcomes. Identifies and resolves barriers that hinder effective patient care.

Qualifications:

• Proficiency in Microsoft Office applications required.
• Must possess current LPN licensure in the state of Tennessee.
• Three years of hospital, health care system, or health plan nursing experience required.
• Knowledge of CMS guidelines and experience working with payer specific guidelines and contractual rules.
• Advanced degree in nursing or related healthcare field is preferred.
• A valid driver’s license is required.
• Graduate from an accredited college or university with a degree in nursing or in a healthcare/business related field is required.
• Case Management certification credentialed by ACMA or CCMC or BLS provider certification preferred.