Coordinator, Utilization Management Access/Part-time

Nashville, Davidson County
May 14, 2014


Coordinator of Utilization Management

Part-time (2 days a week preferably Saturday and Sunday)

3:30pm - 12:00am (Midnight)

This person will be responsible for managing and appropriately status patients in the Emergency  Department to ensure their admission status is correct. 

Facilitates optimal reimbursement through accurate certification. Facilitates throughput of Observation (OBS) patients or inpatients remaining the Emergency Department. Leads Patient Care Continuum (PCC)/Triad/Healthcare team in outcomes based practice in accordance with Vanderbilt University Medical Center (VUMC)/Patient Care Continuum (PCC)/OCM strategic initiatives. Continuously improves knowledge/skills of self and others. Maintains timely oral and written communication.

Key Functions and Expected Performances:

  1. Facilitates optimal reimbursement through certification process
    1. Reviews each case for medical necessity and utilizes InterQual Criteria or Milliman at time the decision is made to keep the patient in the hospital. Reviews appropriateness of inpatient admission or assignment to observation status. Reviews all relevant patient documentation to ensure that the documentation present supports the level of care to which the patient is being admitted.
    2. Collaborates with physicians and other members of the health care team to obtain additional clinical information to ensure that the patient is placed the appropriate level of care and for medical necessity and discharge needs.
    3. Utilizes electronic tools to assure status is correct in hospital systems.

    4. Provides initial/concurrent review to regulatory agencies and contracted insurers. Communicates with payers regarding assessments, utilization of resources, outcomes, and anticipated length of stay.
  2. Facilitates throughput of Observation (OBS) patients or inpatients remaining the Emergency Department.
    1. Collaborates with physicians and all other members of the multidisciplinary team to facilitate and ensure continuity, timeliness and appropriateness of care for ED inpatients and OBS patients; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; and ensures timely:
      a. completion and reporting of diagnostic testing;
      b. initiation and completion of treatment plan
      c. initiation and completion of discharge plan;
      d. assignment of appropriate level of care
      e. completion of all required documentation.
    2. Screens patient for social work, home health, nursing home, or other types of issues and makes appropriate referrals to social worker, case coordinator, nursing home liaison, etc. Communicates any issues to the case manager or social worker on the floor for follow-up.
    3. Knowledgeable about procedures and resources necessary for appropriate discharge planning. Continuously updates knowledge and shares with others. Provides leadership in adapting procedures as indicated by new information
    4. Identifies patterns of care, i.e. frequent admissions, complications, etc. Refers appropriately or develops plans to address.
    5. Provides coordination of patient care consistent with OCM, VUMC, accrediting and regulatory standards
  3. Leads PCC/triad/health care team in outcomes based practice in accordance with VUMC/PCC/OCM strategic initiatives
    1. Leads in the development of processes/systems to measure/monitor practice
    2. Identifies/collects/analyzes appropriate data and assesses against service, PCC and clinical goals.
    3. Utilizes data/research to develop, implement and evaluate programs/systems and improvement plans.
  4. Continuously improves knowledge/skills of self and others
    1. Obtains/evaluates/synthesizes new knowledge/research that is applicable to practice and leads others in applying findings
    2. Adds to knowledge of others via professional activities--presentations, publication, research, policy development/change, and/or professional/community boards
  5. Maintains timely oral and written communication
    1. Maintains clinical documentation per OCM/VUMC and accrediting standards
    2. Communications information in a timely fashion to assure that patient care and/or projects move forward

Basic Qualifications

Job requires a graduate from an accredited Nursing Program and and 3 years of experience or the equivalent.

Emergency Nursing experience strongly preferred

Utlization Management experience preferred

Familiarity with Admissions Criteria a plus

Licensure, Certification, and/or Registration (LCR):

Registered Nurse

Job Medical Coding and Billing

Primary Location TN-Nashville

Organization Case Management 201054PI77407617