UM Inpatient Review and Care RN

This role will ensure that initial and concurrent reviews for all prospective and retrospective inpatient admissions are completed within specified timeframes using evidence based criteria for medical appropriateness to support the admission level. This includes identification and coordination of short and/or long term needs of catastrophically/chronically ill and/or injured persons and their families and coordination of clinical needs across the continuum of care by contacting and establishing links with physicians and other providers and community resources.

Day to Day Duties

Proactive management of acutely and chronically ill members, with the objective of improving quality outcomes and decreasing utilization costs.

Beginning with the day of admission, work collaboratively with facility partners to evaluate and provide feedback to admitting physicians and Discharge Planning staff regarding a member's anticipated discharge plans and coordination of covered services. 

Coordinate an interdisciplinary approach to support continuity of care. Provide utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for members.

Complete telephonic post discharge assessment and assists members with scheduling appointments for PCP, specialists and transportation services as might be needed.

Contact healthcare provider to facilitate notification of admission and to any changes to members individual care plan as a result of the Care Transition.

Early identification and assessment of members for potential inclusion in a comprehensive case management program. Refer members for Case Management accordingly.

Reconcile daily hospital census reports and face sheets against authorizations.