Veracity Software Pvt. Ltd. · 4 months ago
UR Review Case Manager (Admin)
Chicago, IL
Full-time
Onsite
Entry, Mid Level
2+ years expVeracity Software Pvt. Ltd. is seeking a UR Review Case Manager to facilitate the appropriate use of hospital resources and assist with discharge needs. The role involves collaborating with healthcare teams, managing patient data, and ensuring compliance with utilization review standards.
Information Technology & Services
Responsibilities
Performs inpatient utilization management activities as determined by the utilization plan, professional standards and requirements of payers:
Works collaboratively with physicians and other healthcare team members to effect timely and appropriate patient management on an ongoing basis
Collects data as required to support necessity of admission and continued hospitalization based on department standards
Supports the DRG (Diagnosis Related Group) Assurance Program through data collection and ensures that the DRG worksheets contain complete and accurate information and appropriate DRG assignment
Provides accurate clinical information to payers as required
Resolves system problems impeding diagnostic or treatment progress such as delays in the discharge process
Performs non-acute profiling, collecting data on avoidable days and physician advisor referral codes
Assists in the division of Patient Care Services staff in facilitating the safe discharge of patients:
Participates in family meetings and care conferences as needed to resolve identified issues
Ensures timely referrals for discharge planning occur and regional/community resources are utilized when available
Refers complex cases to Social Services as indicated
Uses clinical and social work experts as needed to ensure delivery of comprehensive patient services
Ensures the patient's psychological needs are met through direct intervention or consultation with appropriate discipline
Interacts regularly with physicians and other members of the health team to obtain information about the course of care; provides information in return regarding potential denial of reimbursement or inappropriate level of care:
Refers cases not meeting criteria in a timely manner to the physician advisor
Determines need for and carries out termination of benefits and level of care changes based upon department procedures and maintaining responsibility for related communication and follow-up
Follows up with Medical Director/Physician Advisor to determine outcome or resolution
Central communicator with external and internal customers:
Practices, develops and endorses customer services skills in relationships with internal and external customers
Provide continuity of care by using community resources and maintains updated resource manual for the department
Actively seeks ways to control costs without compromising patient safety, quality of care or the services delivered
Collaborates with multidisciplinary team in facilitating the care of the patients and families within the acute setting and along the healthcare continuum
Attends in-service presentations and completes all mandatory education requirements
Maintains a safe patient care environment by identifying potential safety hazards and intervening appropriately
Operates and maintains equipment used in patient care in a safe manner
Understands and follows infection control requirements in the care of patients
Maintains awareness of hospital changes by reading posted notices, attachments to paychecks and attending scheduled staff meetings
Performs all other duties as assigned
Qualification
Required
Graduate of an accredited school of nursing required
Current RN License in the State of Illinois required
Proficient in Microsoft Word and Excel required
Ability to provide excellent customer service at all times
Preferred
Two years of relevant clinical experience preferred
Previous utilization management experience preferred
Knowledge of Medicare/Medicaid, Managed Care and Commercial insurance review processes preferred
Company
Veracity Software Pvt. Ltd.
At Veracity, if you have an idea you want to validate, a product you need to build, or an existing product that needs optimization, our teams are trained to jump in wherever needed.
51-200 employees
Funding
Current Stage
Growth StageCompany data provided by crunchbase