• Conducts a thorough assessment utilizing approved criteria, protocols, pertinent information available through Plan of Care (POC), patient demographics, Interqual criteria, multidisciplinary rounds (MDRs), consultations, and payor source.
• Applies approved criteria, protocols, UM acuity criteria, to monitor ongoing appropriateness of admission, level of care (LOC), and ongoing stay.
• Documents assessment based on department and criteria standards.
• Monitors length of stay (LOS) and ancillary resource use on an ongoing basis. Takes action to achieve continuous improvement in the throughput process.
• Refers complex cases to the UM Manager and DRB team in compliance with department procedures for support and direction.
• Documents and reports case outliers per department standards - DRB, avoidable days, delays in service, readmits, cost/case reporting, denial and appeals.
• Collaborates with Risk Management (RM)/Revenue Cycle Management (RCM)/Compliance as directed by UM Manager/Team Lead.
• Reviews and understands payor requirements and process and works in collaboration with payor team to achieve appropriate outcomes.
• Identifies barriers and opportunities to improve utilization management and assists in data collection to highlight opportunities for improvement.
• Facilitates peer-to-peer medical review with onsite physician advisor team. Refers to off-site review service post consultation with attending physician and onsite PA.
• Collaborates/communicates with external payor nurse reviewers.
• Understands and is compliant with CMC and CMS process regarding all patient rights documentation and options regarding hospital stay.
• Provides informal education to CMC health care and medical staff regarding all payor and CMS rules and requirements.

Education: Graduate of professional school of nursing required. Bachelor's Degree in Nursing preferred.

Experience: Minimum of three (3) years to five (5) years' experience in clinical healthcare setting with direct patient care responsibilities reflecting planning, coordination, delivery of needed services such as education, discharge planning and utilization management required.

Licensure/Certification: Current licensure in Virginia as Registered Nurse required. Case Management Certification preferred.

Other: Strong oral and written communication skills as well as effective interpersonal skills. Must be effective at teaching individuals from all socio-economic and cultural backgrounds. Must have ability to work without close supervision and demonstrate effective organizational abilities.

This is Carilion Clinic ...

An organization where innovation happens, collaboration is expected and ideas are valued. A not-for-profit, mission-driven health system built on progress and partnerships. A courageous team that is always learning, never discouraged and forever curious.

Headquartered in Roanoke, Va., you will find a robust system of award winning hospitals, Level 1 and 3 trauma centers, Level 3 NICU, Institute of Orthopedics and Neurosciences, multi-specialty physician practices, and The Virginia Tech Carilion School of Medicine and Research Institute.

Carilion is where you can make your own path, make new discoveries and, most importantly, make a difference. Here, in a place where the air is clean, people are kind and life is good. Make your tomorrow with us.