Utilization Review Case Manager Cmc

The mission of Correctional Managed Care is to address the healthcare needs of underserved patient populations within the Texas Department of Criminal Justice (TDCJ) and the Texas Juvenile Justice Department (TJJD).
JOB SUMMARY:
Supports the physician and interdisciplinary team in the provision of patient care (inpatient, outpatient, emergency and infirmary care) with the goal of enhancing quality clinical outcomes, promoting timely access to medical care, and managing care cost and efficient use of medically appropriate services. Integrates and coordinates utilization management activities, care coordination, discharge planning functions, all aspects of Infirmary Bed Management for (506 beds) in the Eastern Sector of Texas, and facilitation/coordination of hospital-to-hospital transfers for offenders in community hospital emergency rooms and community inpatient hospital beds in the Eastern Sector of Texas, and facilitation/coordination of hospital transfers from UTMB TDCJ Hospital to specialty services hospitals.
ESSENTIAL JOB FUNCTIONS:
Utilization Management

• Demonstrates thorough knowledge of Inter Qual Criteria, CMC Specialty Referral Guidelines and Protocols used to determine status for inpatient admission or observation in Community Hospitals and UTMB-TDCJ Hospital.
• Performs Utilization Review procedures by prospectively, concurrently, and retrospectively assessing the clinical information utilizing InterQual criteria, specialty guidelines, and protocols for admissions, observation, emergency care, surgical procedures and urgent clinic referrals.
• Assigns and monitors lengths of stay for all admissions.
• Maintains a documentation system in the AS 400.
• Demonstrates skill in accurately entering required UM data.
• Monitors and facilitates appropriate utilization of resources and provides alternative options to hospital care. (i.e., infirmary placement, urgent clinic)
• Identifies quality of care issues arising during care coordination processes and report issue/concern to the CMC Quality/Risk Management Department.
• Collaborates with UTMB TDCJ Care Managers, Hospital Community Care Managers, TDCJ Bed Placement, and TDCJ Health Services, and internal and external agencies to facilitate care.
• Supports multi-disciplinary strategies to reduce length of stay, reduce resource consumption, and achieve positive patient outcomes.
• Functions as a resource to physicians and nursing staff regarding approved criteria, specialty practice guidelines, and alternative treatment options.
• Provides 24/7 access to care and care coordination through the telephone call center.

Care Coordination

• Conducts daily discharge planning conference with TDCJ Care Managers for patients requiring infirmary bed placement.
• Participates in multidisciplinary rounds for 15 Infirmaries (506 beds) and facilitates clinical care progression, level of care coordination, permanent and non-permanent status, infirmary transfers and discharge planning.
• Facilitates patient care conferences based on special needs of patient.
• Conducts provider conferences for all hospital to hospital transfers and admissions from the prison facility.
• Conducts nurse to nurse conference calls for all infirmary placements, and hospital to hospital transfers.
• Conducts specialty consult conferences between the unit providers and UTMB physicians as needed for patient care.
• Addresses incomplete or unclear clinical information during admission, infirmary placement, urgent clinic requests, and emergency evaluation or hospital transfers. If unsuccessful, elevates to department leadership and Senior Medical Director.

Discharge Planning

• Demonstrates skill in educating providers, community hospital Case Managers and TDCJ Care Managers regarding post-acute options and addresses the level of care availability at infirmaries, while ensuring security needs are met as well as clinical needs.
• Demonstrates skill in developing discharge plans for the offender/patient with the receiving unit or infirmary nursing staff, medical staff and transport services.
• Adjusts and manages barriers to discharge plans.
• Collaborates with care managers, providers, nursing and pharmacy to facilitate identified discharge needs and ensure services provided at destination infirmary.
• Collaborates with TDCJ Health Services Liaison to coordinate general population reassignments.

Infirmary Bed Management

• Demonstrates knowledge of how to strategically plan and prioritize, on a daily basis, infirmary placements for discharges from community hospitals and UTMB TDCJ Hospital, and request from prison facilities and TDCJ Health Services for County intakes from Texas counties.
• Demonstrates knowledge of CMC Infirmary Criteria, CMC Nursing Needs, Medical and Support Services available at each infirmary, TDCJ Health Services Facility Types List, and CMC Formulary to determine admission to the appropriate Infirmary.
• Participates in multidisciplinary rounds for 15 Infirmaries (506 beds) and facilitates clinical care progression, level of care coordination, permanent and non-permanent status, infirmary transfers and discharge planning.
• Demonstrates skill in reviewing infirmary requests, assessing clinical needs, type of bed and best location for patient to receive the care ordered by the provider, while coordinating with TDJC security regarding security restrictions, patient transport and any special non formulary medications.
• Ensures timely intervention to prevent delays in placement and transition of care.
• Identifies, adjusts and manages barriers to discharge and infirmary placement.
• Identifies quality of care issues arising during infirmary placement and reports issue/concern to the CMC Quality/Risk Management Department.
• Demonstrates strong problem solving skills and ability to coordinate and manage case load of patients for infirmary placement.
• Demonstrates timely and thorough documentation in AS 400, email completion for transport and nurse to nurse conference.
• Monitors length of stay timeframe and implement measures to achieve target.
• Presents LOS variances for review to Director and Inpatient Medical Director.

Transfer Center (Hospital to Hospital Transfer and Direct Admits)

• Demonstrates thorough knowledge of the transfer process for transferring patients from one hospital to another for ER Evaluation, observation or inpatient admission.
• Facilitates transfer process by conducting conferences between the requesting and accepting physician, nursing and the CMC PECC (Patient Evacuation Command Center), and obtains bed via the community hospital transfer center or the TDCJ Bed Placement Center
• Collaborates with the community Case Managers, Physicians, Nursing, UTMB Physicians, and UTMB Nursing Triage to facilitate the transfer and/or direct admit.
• Ensures timely intervention to prevent delays in transfer and transition of care.

Case Management

• Assists health care providers in monitoring patients with complicated treatment plans through multidisciplinary conferences and medical record review.
• Facilitates clinical care progression of patient throughout treatment program.
• Contacts appropriate support services and/or ancillary departments with any delays impacting care progression.
• Demonstrates timely and thorough Documentation in databases.

Other

• Adheres to internal controls and reporting structure established for department.
• Performs related duties as required.

KNOWLEDGE/SKILLS/ABILITIES:

• Maintains clinical expertise in specialty area and or general nursing.
• Assumes responsibility for remaining current on job-related knowledge and skills and ongoing education/in service/certification requirements.
• Utilizes effective communication, conflict management, and negotiation skills.
• Must be self-motivated, willing, and able to learn multiple aspects of the job.
• Demonstrates competency and skill in communication with health care providers, internal and external customers.
• Demonstrates collaboration, professionalism and ability to work with all health care providers, and staff.
• Demonstrates capacity to manage "crisis situations."
• Demonstrates skill in prioritizing case load for appropriate level of care and coordinating and managing continuum of care.
• Performs a variety of marginal duties not listed, to be determined and assigned as needed.
• Participates in research activities/projects
• Provides assistance regarding clinical issues to non-nursing Utilization Review staff
• Demonstrates support of the department and active participation in improving performance and achieving departmental goals.

EQUIPMENT:
Standard office equipment.
WORK ENVIRONMENT:
Standard office environment. May involve shift work and weekends as needed to accommodate operations 24 hours a day, 7 days a week.
Security clearance is required; pre-employment drug testing is also required.
REQUIRED EDUCATION/EXPERIENCE:

• Current Texas licensure as a Registered Nurse (RN).
• Bachelor's Degree in Nursing with a minimum of three (3) years full-time wage earning experience as a professional nurse in a hospital or healthcare setting.

Salary is commensurate with years of relevant work experience.
Equal Employment Opportunity
UTMB Health strives to provide equal opportunity employment without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, genetic information, disability, veteran status, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. As a VEVRRA Federal Contractor, UTMB Health takes affirmative action to hire and advance women, minorities, protected veterans and individuals with disabilities.