JOB SUMMARY :
LOCATION: JOHN H. STROGER HOSPITAL / INTEGRATED CARE - CHICAGO, IL.
SHIFT: VARIES
The Utilization Management Coordinator, Emergency Department (UMC) serves an important role to support Cook County Health & Hospitals System (CCHHS) goals of efficient, effective, patient-centric care. Using the electronic medical record (EMR) and consulting with the treatment team, the UMC determines if the patient is in the appropriate level of care and if clinical milestones are being met in a timely manner. The UMC provides timely feedback to the treatment team and makes appropriate referrals to other care coordination components for those patients who have barriers to discharge or whose condition requires a different level of care. The successful UMC has a sound clinical foundation, knowledge of utilization management, and critical thinking skills to support effective, timely communication regarding case status. This position requires days, evenings and weekend hours.
This position is exempt from Career Service under the CCHHS Personnel Rules.
Typical Duties
- Verifies payer status and medical home (documents same in notes)
- Reviews cases being proposed for inpatient or observation at Stroger and Provident Hospitals within one hour of notification.
- Provides continued stay review at intervals appropriate to the treatment plan and anticipated patient progress.
- Review reflects the ability to:
o Translate signs, symptoms, lab values, diagnostic testing results, to a MCG guideline. For example the UMC is able to discern the origin of shortness of breath based on history, clinical presentation, vital signs and test results to select the appropriate guideline.
o Document all relevant information in case notes
o Detects and documents trends and in clinical and functional status data to assess patient progress
- Correctly assigns medical necessity determination and level of care. If different than current assignment, notifies treatment team to alert them and provides recommendations.
- Identifies and refers cases at risk-
o Readmissions within 30 days
o Failure to meet guidelines (either on initial or concurrent review)
o Multiple social determinants impacting care or treatment
o Active MH or SUD
o Those requiring on-going care coordination
o Managed Care Required care coordination
o Planned re-admission requiring pre-certification
- Uses portals to forward clinical information to payers
- Communicates succinctly and efficiently with stake-holders such as insurance companies, physicians, Inpatient Care Coordination Specialist,
- Escalates case when EMR documentation doesn't support medical necessity requirement and outreach has not closed gaps.
- Supports and organizes peer to peer conversations to avoid potential denials.
- Participates in departmental quality improvement guidelines
- Completes all educational efforts for CCHHS and licensure
- Completes 25 reviews per day
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