RN Case Manager​/Utilization Review - Case Management - Rotating Shifts; Non-Ex

Overview

The RN Float Case Manager and Utilization Review Nurse provides coverage for an RN Case Manager or RN Utilization Review Nurse. The RN Float Case Manager and Utilization Review Nurse is assigned to function in the role of either a RN Case Manager or RN Utilization Review Nurse, as provided below.

RN Case Manager role: In collaboration with the interdisciplinary team, provides care coordination services evaluating options and services required to meet an individual s health care needs to promote cost-effective, quality outcomes. Serves as a consultant to members of the health care team in the management of specific patient populations. The RN Case Manager role integrates the functions of utilization management, quality management, discharge planning assessment, and coordination of post-hospital care services, including transfers to an alternative level of care.

RN Utilization Review Nurse role: The RN Utilization Management Specialist coordinates communication with admitting financial counselors, case management team, providers, patient financial services, and payers to ensure all services provided by the hospital are authorized by appropriate payer. The RN Utilization Management Specialist confers and reviews with physicians on medical admitting information to assess medical necessity and uses evidence-based criteria to consider the anticipated length of stay, level of care, and intensity of service to support access to services.

The RN Utilization Management Specialist facilitates timely transmission of admission, concurrent and discharge reviews to the appropriate payer to ensure all days are authorized and documented. Clinical reviews and continued stay authorizations will be documented in the appropriate electronic system.

• RN Case Manager - Position Accountabilities 1. Able to effectively manage a minimum case load of 18-20 patients.
  2. Completes initial discharge planning evaluation within one business day and identifies high risk indicators for discharge planning and/or need for psychosocial interventions and integrates with Social Work Case Manager/Discharge Planning Coordinator as needed.
  3. Actively participates in multidisciplinary rounds and discharge huddles as required, focusing on targeted discharge date and patient care progression.
  4. Identifies high risk indicators for discharge and/or needs for psychosocial interventions and involves Social Work team member as indicated.
  5. Analyze and interpret data in collaboration with patient, family, physician, health care team to develop a plan of care.
  6. Develops and implements referrals/placements/interventions: LTAC, subacute, home care, home care with therapy services, home care with DME services, Durable Medical Equipment/oxygen, infusion therapy, wound care, and acute to acute hospital transfers.
  7. Notifies attending physician and medical physician advisor of any discharge planning barriers or issues, assists with coordinating Peer to Peer reviews, and documents interactions and outcomes in the electronic case management system.
  8. Demonstrates collaborative working relationship with social workers to ensure patient psychosocial needs are met while coordinating care (i.e., planning and implementing discharges to private duty care, skilled nursing facilities, end of life, hospice, and palliative care). 9. Coordinates acute to acute transfers as requested by payers to return patients to in network facilities. 10. Adheres to regulatory requirements as defined by CMS Conditions of Participation and/or health plan, serving regulatory letters as indicated (e.g., MOON, HINN, ABN, and Code 44).
  
  11. Serves as a consultant to the health care team to identify financial issues that may affect care. 12. Participates in the education of health care team members on current healthcare issues impacting practice patterns and reimbursement. 13. Educates physicians and health care team on patient status, as appropriate. 14. Delegates and supports team members to facilitate discharge planning. 15.
  
  Adheres to hospital and department protocols, workflows, policies, procedures, standards and competencies for clinical role. 16. Participates in Inter Qual competency testing as requested by department director. 17. Participates in hospital quality improvement processes and helps identify opportunities to improve care. 18. Strives to support and contribute to the success of the department outcome metrics, key performance indicators and/or department goals and objectives.
  
  19. Identifies compliance and ethical issues and reports appropriately. 20. Work with post-acute services to address educational needs to ensure a safe discharge plan. 21. Identifies and creates discharge planning solutions, proposes alternative treatment options to ensure a cost effective and efficient plan of care. 22. Enters information concurrently into the electronic medical record and utilizes case management module to update, track and record outcomes as indicated.
  
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