Manager of Care Transitions and Utilization Review

Job Details: Job Location: Corporate

• Oneida, NY, Position Type: Full Time, Salary Range: $95000.00 - $115000.00Salary/year, Job Shift: Days, The Manager, Care Transitions and Utilization Review at Oneida Health Hospital plays a crucial role in facilitating patient education, assessments, and counseling within hospital clinical departments. This position requires a comprehensive understanding of utilization review (UR), case management, and discharge planning to ensure the delivery of high-quality, cost-effective care.

Key Responsibilities

Conduct comprehensive reviews to determine the medical necessity of extended stays, outpatient observation, inpatient stays, and ancillary services. Review and monitor healthcare service utilization, ensuring high-quality, cost-effective care. Coordinate and conduct medical necessity reviews for all payer categories, including Medicare, Self-pay, and others, both upon admission and concurrently throughout the admission process.

Review clinical documentation, ensuring compliance with government regulations and accurate representation of service levels and severity of illness. Facilitate modifications to documentation as needed and perform initial and concurrent reviews for all patients entering the healthcare continuum. Interface with the Care Transitions team to provide information on quality outcome measurements and collaborate on timeliness and appropriateness of services.

Collaborate with physicians, case managers, payers, and other stakeholders to appeal individual denials and address trended issues related to contract guidelines. Work with medical records, finance, and physician groups to develop systems facilitating complete documentation for data reporting purposes. Initiate chart reviews, conduct follow-up reviews, and round on patients to ensure continuity of UR assessments.

Maintain a system to identify admissions with specific diagnoses/DRG classifications, promptly notifying attending physicians and appropriate staff of documentation issues requiring clarification. Other job related duties as assigned by the management. Additional Responsibilities: Determine qualifications for hospital level of care based on set criteria.

Actively participate in the Utilization Review Committee. Perform other duties as assigned. Physical Requirements: The Care Transitions RN Utilization Review Specialist is required to meet specific physical demands to effectively perform the essential functions of the job, including but not limited to mobility, manual dexterity, vision, hearing, communication, lifting, extended periods of sitting, standing and walking, stamina, stress tolerance, and team collaboration.

Reasonable accommodations may be considered to enable individuals with disabilities to fulfill the essential functions.

Qualifications

Education

Associate's or Bachelor's Degree in Nursing from an accredited institution (Required). Experience: 2 years as a Registered Nurse in an acute care setting, with at least 1 year of experience in UR/UM or Case Management (Required). PRI certification is preferred. Licenses and Certifications: Registered Nurse (RN) State and/or Compact State Licensure (Required).