The Case Manager and Utilization Review, CRMC performs a collaborative process of assessment, planning, facilitation, care coordination, evaluation, advocacy for options/services to meet an individual's/family's comprehensive health needs at Capital Region Medical Center for quality and cost-effective outcomes. This role provides utilization review at admission, collaborates with providers, ensures patients appropriate level of care, and ensures correct reimbursement to minimize payment denials.

Location: Columbia, Missouri
Shift: Part time days/evenings as needed, occasional weekends
Department: Care Coordination
Salary Range: $59,322 to $96,762 based on experience

Essential functions:

1. Assess clinical care progression using Interqual and EHR tools to determine whether patients are admitted to the appropriate accommodation. Notify admitting physician of discrepancies and provide a rationale.
2. Evaluate patient admission status upon admission notification. Deliver and complete all assessments within 24 hours of the patient's admission.
3. Assess patients for care coordination risks and transitional/discharge needs within 24 hours of admission. Integrate family information, and work collaboratively with the SW to determine potential and actual transitional/discharge needs, and the next level of care needed.
4. Issue the Hospital Issued Notice of Noncoverage to Medicare recipients when appropriate.
5. Work proactively with the hospital system, patient, family, community agencies, and physicians when potential barriers or avoidable days are identified.
6. Utilize tools/technology to identify/intervene with patients at risk for readmission. Intervene to discuss readmission challenges, including writing a Unique Treatment Plan and communicating with PCP/post-acute caregiver.
7. Partner with the interdisciplinary team on information regarding length of stay (LOS) guidelines. Utilize tools/technology and medical necessity criteria to ensure medically appropriate (LOS) and appropriate accommodation/optimal LOS.
8. Ensure complex clinical care services and resource management are in place at the time of discharge.
9. Demonstrate awareness of and adhere to compliance regulations.
10. Provide leadership in the professional practice setting. Function as a professional role model, promote a positive work environment, and participate in shared decision-making. Function as part of a positive and collaborative team utilizing relationships with social workers, pharmacy, physicians, hospital staff, patients, families, and post-acute providers.
11. Maintain a safe environment for patients/visitors/employees. Support data requirements, and establish/measure productivity. Participate in department quality audits/improvement initiatives. Identify opportunities to improve care management. Participate in unit/hospital/system-wide PI initiatives that impact patient care and resource utilization.
12. May complete unit/department specific duties and expectations as outlined in department documents.

Required Qualifications:

1. Two (2) years of clinical experience.
2. One of the following: -Master of Social Work degree, or Licensed Master Social Worker (LMSW) or Licensed Clinical Social Worker (LCSW) licensure by the Missouri State Committee for Social Workers board, or -Missouri Board of Nursing RN or Nurse Licensure Compact multi-state RN. When primary state of residency changes, compact state RNs must apply under new state of residency within thirty (30) days, or -Occupational Therapist (OT) licensure by the Missouri Board of Occupational Therapy, or -Speech Language Pathologist (SLP) licensure by the Missouri Commission for Speech-Language Pathologists, and Certificate of Clinical Competency (CCC) certification from American Speech-Language-Hearing Association (ASHA), or -Physical Therapist (PT) licensure by the Missouri Board of Registration for the Healing Arts or PT Compact multi-state privilege. When primary state of residency changes, compact state PTs must apply under new state of residency within thirty (30) days.

Preferred Qualifications:

• Bachelor's degree in nursing or healthcare related field.

• Case management certification or other related specialty.

• Experience in case management, social work or utilization management work.

• Additional license/certification requirements as determined by the hiring department.

Physical Demands: The physical demands described here are representative of those that must be met with or without reasonable accommodation. The performance of these physical demands is an essential function of the job. The employee may be required ambulate, remain in a stationary position, and position self to reach and/or move objects above the shoulders and below the knees. The employee may be required to move objects up to 10 lbs