Allegheny Health Network
Job Description :GENERAL OVERVIEW:
Registered nurse who is proficient in the coordination of care and manages coordination of care in accordance with recognized standards of practice for Care Management. Professional role model utilizing expertise in care management to promote a collaborative professional environment that supports excellence of care and achievement of optimal resource utilization. Also facilitates appropriate LOS, patient satisfaction and reimbursement for all patients.
Assumes role in assessment of patient physical, psychosocial, and economic needs for effective transition of care planning to a variety of levels of care.
In collaboration with the care team, facilitates the development and communication of the continuum of care transition plan to appropriate health service providers.
Documents, verifies, and validates specific data required to monitor and evaluate interventions and outcomes. Interviews and collects patient specified data and chart review related to readmission.
Knowledgeable of and complies with accreditation and regulatory requirements. Integrates performance improvement principles and customer service principles into all aspects of job responsibilities.
Obtains or ensures acquisition of appropriate pre-certification authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party guidelines. Obtains or facilitates acquisitions of urgent / emergent authorizations, continued stay authorizations and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements.
Documents, monitors, intervenes/resolves and reports clinical denials/appeals and retrospective payer audit denials. Collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor and third party payers.
Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental commercial payer guidelines. Adheres to the policies, procedures, rules, regulations and laws of the hospital and all federal and state regulatory bodies. Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
Assumes responsibility for AHN required continued education and own professional growth. Performs other duties as assigned or required.
BA/BS degree and nursing diploma.
2-3 years of recent clinical RN acute care experience
Current PA RN license
Nationally recognized Care Management Certification within 5 years of start date (3 years for currently employed)
Discharge planning and community resource knowledge
Care facilitation and utilization review experience
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