Case Management Utilization Checklist

NAME

LAST 4 OF SSN

Date of application

E-MAIL

I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.

Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.

Ranking: 0%

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

SETTING	Rating Stars (Click)	1	2	3	4
Acute Care�
Skilled/LTAC�
MDS Coordinator�
Home Health�
Telephonic�
Workers Compensation�
Insurance�
Managed Care�
Acute Rehab
CM/UR SOFTWARE	Rating Stars (Click)	1	2	3	4
Interqual�
Milliman�
MIDAS�
Allscripts UR�
Word Processing Software�
Other: Specify�
Other: Specify
REGULATORY	Rating Stars (Click)	1	2	3	4
CMS/Medicare�
HEDIS Measures�
Core Measures�
Medicaid/Medical�
DRG�
ICD 9 Coding�
ICD 10 Coding�
CPT
PROCESSES	Rating Stars (Click)	1	2	3	4
Benefits Eligibility�
Pre-Certification Review�
Review for Admission Criteria�
Identify Appropriate Level of Care�
Review Status During Stay�
Discharge Planning�
Physician Advisor�
Clinical Documentation Improvement�
Needs Assessment/Order DME�
Needs Assessment/Home Health�
Needs Assessment/Hospice�
Needs Assessment/Skilled�
Third Party Authorization Process�
Concurrent Review�
Retrospective Review
PROFESSIONAL KNOWLEDGE AND SKILLS	Rating Stars (Click)	1	2	3	4
National Patient Safety Goals�
Age Specific/Population Based Care
Age Specific Competencies	Rating Stars (Click)	1	2	3	4
Infant (Birth - 1 year)
Preschooler (ages 2-5 years)
Childhood (ages 6-12 years)
Adolescents (ages 13-21 years)
Young Adults (ages 22-39 years)
Adults (ages 40-64 years)
Older Adults (ages 65-79 years)
Elderly (ages 80+ years)
EMR	Rating Stars (Click)	1	2	3	4
Epic�
Cerner�
Eclipsys�
McKesson�
Meditech�
Allscripts�
Other: Specify