Job Description

Acute Utilization Review Case Manager

Cancer care is all we do

Hope in healing

Cancer Treatment Centers of America® (CTCA®) takes a unique and integrative approach to cancer care. Our patient-centered care model is founded on a commitment to personalized medicine, tailoring a combination of treatments to the needs of each individual patient. At the same time, we support patients’ quality of life by offering therapies designed to help them manage the side effects of treatment, addressing their physical, spiritual and emotional needs, so they are better able to stay on their treatment regimens and get back to life. At the core of our whole-person approach is what we call the Mother Standard® of care, so named because it requires that we treat our patients, and one another, like we would want our loved ones to be treated. This innovative approach has earned our hospitals a Best Place to Work distinction and numerous accreditations. Each of us has a stake in the successful outcomes of every patient we treat.

Job Description:

Schedule: Monday-Friday: 8:00am - 4:30pm; Required call rotation on weekends.

Provides, coordinates and facilitates patient discharge planning in collaboration with other healthcare professionals during hospitalization.  Assists with organizing services across provider lines, between people and systems to affect optimal patient outcomes, achieve continuity of care and reduce costs.  Serves as a utilization management resource to determine appropriateness of admission, level of care and continued stay.  Maintains a working knowledge of Medicare and private insurance companies and ensures that quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting data to appropriate person(s) and/or department(s). Performs other duties as assigned and accepts new tasks as opportunities for growth.

Discharge Planning Responsibilities:

  • Collaborates with health care team members to develop a multidisciplinary plan of care and sets patient-centered goals for patient/families.  Facilitates and/or participates in discussions that provide ongoing evaluation of interdisciplinary intervention, goal attainment, and treatment plan revision.
  • Knowledgeable about the patient’s financial status, diagnosis and discharge needs to develop the discharge plan of care.  Also maintains an awareness of the patient’s psychosocial situation, including identification of potential barriers which may impact patient compliance and facilitates the coordination of referrals as appropriate.
  • Develops collaborative relationships with other departments/entities/external health care agencies to facilitate and support care.
  • Initiates discharge planning assessment at the time of admission and collaborates with the multi-disciplinary  team for timely discharge. Identifies anticipated discharge date, assesses needs and coordinates services, financial implication of care internally and externally to meet patient needs, including, but not limited to, medications, equipment and home care.
  • Assist as needed with obtaining referrals and prior authorization(s) for Home Health Care, hospice, infusion therapy, Durable Medical Equipment (DME), Skilled Nursing Facility (SNF), acute rehab and appointments.

Utilization Review Responsibilities:

  • Provides ongoing communication with patients, families, medical staff, care givers and third-party payers, to include utilization assessment for pre-certification and continued stay justification.  Refers cases that do not meet criteria to the Medical Staff leader.
  • Communicate with providers to ensure clinical documentation supports the service and level care provided to the patient.  
  • Act as a liaison between CTCA Phoenix and outside agencies (Medicare/Medicaid, commercial, and managed care payers) by providing initial and concurrent clinical reviews (both written and verbal) in order to secure insurance authorization and appropriate reimbursement
  • Provides concurrent review of patient admission data within the designated time frames to determine suitability of the level of care in accordance with established criteria.  Works with facility coder to assist with queries requested and concurrent coding needs

Functional Competencies

  • Ability to utilize a clinical reasoning process for assessing, planning, implementing and evaluating the patient’s plan of care while ensuring that coordination of services is done in a timely manner.
  • Demonstrates sound knowledge and actions in the care and decision making for the oncology patient population and seeks guidance appropriately.
  • Ability to maintain confidentiality of all medical, financial, and legal information
  • Maintains a working knowledge of Medicare and private insurance company coverage for referred products and services.
  • Demonstrates proficiency in managing multiple and simultaneous responsibilities and to prioritize scheduling of work
  • Ability to extract and review relevant medical documentation and uses nationally recognized acute care indicators and established criteria to make independent, accurate daily medical necessity, level of care, and length of stay determinations for all observation and inpatient cases
  • Ability to communicate effectively both orally and in writing
  • Demonstrates effectiveness in dealing with difficult situations in a professional manner
  • Ability to attain and interpret data based on utilization criteria.  Provides input to multidisciplinary groups regarding variances in statistical data and suggests and oversees process improvements related to utilization management and discharge planning.
  • Proficient in maintaining required documentation (i.e. ongoing insurance communication and discharge planning).
  • Collaborates with multi-disciplinary teams to ensure appropriate financial reimbursement and patient care coordination
  • Serve as a resource and educator regarding utilization review, discharge planning coordination, and clinical documentation principles as needed

JOB QUALIFICATIONS

  • 1-year experience as a Case Manager and /or Utilization Review RN or similar role is required, 2 years of Case Management experience with 2 years of Oncology experience/knowledge preferred
  • ADN in Nursing is required, BSN in Nursing
  • Current Arizona RN Licensure is required
  • American Heart Association (AHA) *Basic Life Support (BLS) provider card or ability to obtain the card within 30 days of hire
  • Knowledgeable and able to navigate computer-based applications such as Microsoft products, review software and the electronic medical record
  • Certified Case Manager; Certified Managed Care Nurse is preferred
  • Knowledge of ICD and PCT coding preferred

Additional Qualifications:

  • Sitting ,Frequent Crawling, Occasional Walking, Occasional Neck Twisting, Occasional Simple Grasping, Occasional Standing, Occasional Climbing
  • Occasional Kneeling, Frequent Waist Bending, Occasional Talking, Frequent Reach Above Shoulder, Occasional Squatting, Frequent Reaching at or Below Shoulder

We win together

Each CTCA employee is a Stakeholder, driven to make a true difference and help win the fight against cancer. Each day is a challenge, but this unique experience comes with rewards that you may never have thought possible. To ensure each team member brings his or her best self, we offer exceptional support and immersive training to encourage your personal and professional growth. If you’re ready to be part of something bigger and work with a passionate, dynamic group of care professionals, we invite you to join us. 

Visit:  Jobs.cancercenter.com to begin your journey.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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