RN Case Manager - Utilization Review 51

Job summary

Job description/Responsibilities: Full-Time (1.0) AM Shift (every other weekend) APPOXIMATE PAY RANGE: $40.91 - $50.31

POSITION SUMMARY Under general supervision is responsible for assisting in carrying out the hospital's Case Management Plan. Functions as a member of the multidisciplinary health care team to facilitate patient movement through the continuum of care and back into the community. As part of the team, makes decisions regarding utilization management and alternative treatment which reflect cost-effectiveness. Provides interface with internal departments and external departments and agencies.

Is cognizant of regulations and policies of all review organizations relating to billing of the fiscal intermediaries coordinates, monitors and evaluates options and services to meet an individual's health needs.

ESSENTIAL DUTIES

• Monitors utilization practices from admission to discharge to assure cost-effective, quality patient care and to ensure that patient, physician, and hospital receive maximum benefits from the health plan.
• Evaluate high-risk/age-specific patient clinical status and anticipated post-hospital needs within 48 hours of the first business day following admission.
• Assesses patient's needs for healthcare resources and agrees on needs with patient, family, and healthcare team.
• Assesses patient's financial status, insurance benefits, available resources, and type of resources.
• Collaborates with members of the interdisciplinary healthcare team to continuously monitor patients' conditions. Identifies and communicates problems. Trends (lack of resources, systems impediments, etc.) that impede efficient delivery of care. Working collaboratively with Discharge planners and Social Workers.
• Evaluate the effectiveness and appropriateness of care/services and make timely revisions to facilitate patients through the continuum of care, ensuring effective, high quality, and cost-effective results.
• Builds and supports a healthy and satisfying work environment that fosters the transfer of information.
• Performs effective handoff to ensure an effective transfer of knowledge using the stability of the patient’s condition and interdisciplinary plan of care.
• Attend and actively participate in all departmental and interdepartmental meetings relative to Case Management/ Social functions.
• Documents clearly and concisely all contacts and information of the patient’s case management process on the appropriate chart forms.
• Educates physicians and staff regarding the appropriate level of care/utilization issues.

ER Case Manager

• Evaluate the medical necessity for admission, and appropriateness of patient care unit placement for all ER admissions when on duty.
• Upon discharge of the patient from the ER, will coordinate clinical and financial discharge planning needs as necessary so that a smooth transition from the acute outpatient care setting to the community setting is ensured.
• Utilizes the resources of the Social Worker as necessary to provide a quality discharge plan.
• Dialogues with the payers as necessary to guarantee appropriate reimbursement.
• Communicates with physicians and other members of the interdisciplinary healthcare team to ensure appropriate utilization of resources and implementation of clinical practice guidelines or standing orders to meet expected standards of care.
• Acts as an overall liaison between patients and community resources in collaboration with Social workers.
• Serves as the liaison for the other members of the interdisciplinary team to ensure appropriate and expedient referral upon the decision to admit to the acute inpatient setting.

PROFESSIONAL RESPONSIBILITIES

• Maintains current knowledge of Case Management/Social Services, discharge planning, and nursing issues through continuing education.
• Suggests and introduces new methods and techniques.
• Participates in professional activities in order to continue their professional development and contribute to that of the profession.

Required

Qualification:

EDUCATION Graduate of an accredited School of Nursing required.
** Proof of all required educational levels due at time of hire QUALIFICATIONS
* License/Certification Current RN license…