Utilization Management Admissions Liaison RN II

Job Summary

The Utilization Management (UM) Admissions Liaison RN II is primarily responsible for receiving/reviewing admission requests and higher level of care (HLOC) transfer requests from inpatient facilities within regulator timelines.  Reviews clinical data in real-time and post admission  to issue a determination based on clinical criteria for medical necessity.  Assures timely, accurate determination and notification of admission and inter-facility transfer requests. Generates approval, modification, and denial communications for inpatient admission requests. Actively monitors for  appropriate level of care (inpatient vs. observation) admission in the acute setting.  Works with UM leadership, including the Utilization Management Medical Director, on  requests where determination requires extended review.  Collaborate with the inpatient care team for facilitation/coordination of patient transfers between acute care facilities.  Acts as a department resource for medical service requests/referral management and processes.   Actively participates in the discharge planning process, including providing clinical review and authorization for alternate levels of care, home health, durable medical equipment, and other discharge needs.  Provides support to the inpatient review team as necessary to ensure timely processing of concurrent reviews.

Duties

Provides the primary clinical point of contact for inpatient acute care hospitals requesting Inpatient care/post-stabilization admission requests, Higher level of care transfers and other emergent transfers or needs. Ensures appropriate determination for admission requests/HLOC transfers based on clinical data presented and established criteria/guidelines, escalating to the medical director if needed.  Triages and assesses members for admission needs, including, but not limited to, bed and accepting physician availability. (40%)

Establishes and maintains ongoing communication with internal stakeholders and external customers while securing the L.A. Care member's admission or inter-facility transfer.  Interfaces with physicians, house supervisors, and other hospital delegates to ensure that telephone triage results in appropriate patient placement. (10%)

Applies clinical expertise and the nursing process to triage and prioritize admission acuity, servicing as an expert clinical resource for patient placement while utilizing medical knowledge and experience to facilitate consensus-building and development of satisfactory outcomes (10%)

Continually seeks new ways to improve processes and increase efficiencies. Takes the initiative to communicate recommendations to UM Leadership. (5%)

Completes all inpatient and discharge planning requests appropriately and timely including, but not limited to:  Skilled nursing facility, outpatient needs (home health, physical therapy, infusion), and case management referrals (5%)

Performs prospective, concurrent, post-service, and retrospective claim medical review processes. Utilizes clinical judgement, independent analysis, critical-thinking skills, detailed knowledge of medical policies, clinical guidelines and benefit plans to complete reviews and determinations within required turnaround times specific to the case type. Identifies requests needing medical director review or input and presents for second level review (20%)

Performs other duties as assigned. (10%)

Duties Continued

Education Required

Education Preferred

Experience

Required:
Minimum 5-7 years of clinical experience in an acute hospital setting. 

Previous experience to have a strong understanding of Utilization Management/Case Management practices including, but not limited to, placement (with level of care) criteria (MCG, InterQual), concurrent review, and discharge planning.

Preferred:
Consistent Critical Care experience (Emergency Department, Intensive Care, Labor & Delivery) background highly desirable.

Experience in bed placement decision-making highly desirable.

Skills

Required:
Must be computer literate, with expertise in Outlook, Word, Excel, PowerPoint.  

Provision of excellent customer service required due to frequent communication with providers and other members of the interdisciplinary team  

Knowledge of personal computer, keyboarding, and appropriate  software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Prepare clear, comprehensive written and oral reports and materials. 

Excellent time management and priority-setting skills.

Maintains strict member confidentiality and complies with all HIPAA requirements.

Strong verbal and written communication skills.    

Preferred:
Knowledge of National Committee for Quality Assurance (NCQA) requirements for Utilization Management or CM. 

Knowledge of Department of Health Care Services (DHCS) or Centers for Medicare and Medicaid Services(CMS) requirements for health plan compliance with UM or CM.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

Required:
Attend mandatory department trainings as scheduled

Financial Impact: Management of all medical services has a tremendous potential impact on the cost of health care and budget. This position manages determinations to ensure services requested are medically appropriate and provided in the most cost effective manner without compromising quality healthcare delivery.

Types of Shift:  Day (7:00am - 3:30pm), Evening (3:00pm -11:30 pm), Night (11:00pm -7:30am). 
Float (Varies)*
*All possible shifts.