POSITION SUMMARY
Functions independently and collaboratively to assure appropriate utilization of resources for patients across the continuum of care. Responsible for facilitating a timely and effective discharge plan in collaboration with the patient/family physician and other care givers. Coordinates patient care across an episode of care.
MINIMUM REQUIREMENTS
Education & Experience:
- An Associate Degree or Diploma RN with a minimum of five years acute care clinical experience or two years case management experience.
- Preference is given to registered nurses with a bachelor or master degree in nursing and previous utilization management experience.
Knowledge, Skills, Abilities:
- Knowledge of hospital admitting procedures, health care legislation and government/regulatory health related agencies.
- Demonstrates an ability to communicate effectively and express ideas clearly; actively listens.
- Works well with others to solve interpersonal conflicts and problems without need of superiors.
- Demonstrates an ability to identify and solve problems.
- Computer skills are desirable.
License/Certification/Registration:
- If training is in Nursing, incumbent must be licensed as a Registered Nurse in the State of Pennsylvania.
- Meets the American Heart Association’s standards for Healthcare Provider Basic Life Support (BLS) and renews BLS every two years.
SUPERVISION RECEIVED
Receives minimum supervision from the Director, Population Health and Case Management. Functions independently; seeks guidance when necessary.
SUPERVISION GIVEN
None
ESSENTIAL FUNCTIONS
Performs concurrent review of patients admitted to the hospital to determine length of stay, medical necessity and appropriateness of admission based on approved criteria and standards.
Determines an initial length of stay to all reviewed admissions deemed to be medically necessary and appropriate as assigned.
Refers cases where necessity for admission, length of stay, or level of care is questioned, or when no criteria are available, to the Utilization Review physician designee.
Verifies, coordinates, reviews and monitors patient access to services including but not limited to patients for observation and transfers from acute care facilities.
Maintains system for monitoring all admissions to assure review of extended stays in a timely manner, collect information, document and make recommendations with regard to medical necessity and appropriateness of extended stay using approved criteria and standards.
Maintains a system for monitoring concurrent review with availability of statistics and documentation showing an orderly flow of information and reviews.
Coordinates outpatient and emergency patient information flow from admissions to billing to avoid reimbursement issues.
Assists in compiling required reports on all Utilization Review activities mandated by law; maintain appropriate files for established time periods.
Communicates with payor-based and alternative care based managers/professionals.
Provides physicians, caregivers and others with pertinent regulatory, reimbursement, changing environment updates for effective utilization of resources.
Initiates, facilitates, and coordinates appropriate discharge planning/resource mobilization with patients/families.
Screens each admission based on discharge planning criteria in a timely manner; determine, in collaboration with others, whether discharge planning is simple or complex.
Reviews complex discharge plans with other care managers.
Initiates daily discharge planning team encounters as necessary.
Formulates appropriate discharge plan with patients/family.
Ensures timely, coordinated access to appropriate levels of care, support services, and continuity of care.
Maximizes the appropriate use of personal and internal resources.
Links the patient to community and formal resources as needed.
Reviews appropriate patients with DME providers, home health liaisons, rehab liaisons, nursing home representatives, personal care home providers, and other community service providers, as needed.
Assesses psychosocial factors of patients/families, including those in crisis, through interview and other means and formulation of documented treatment plan.
Sees patient consults within appropriate time frame, documents same at time of consult; prioritizes consults utilizing designated standards.
Interprets psychosocial factors to physicians and other caregivers.
Facilitates understanding of medical recommendations.
Engages and mobilizes patient and family coping strengths.
Educates patient and family regarding risk factors for optimal psychosocial function.
Counsels patients/families regarding illness, discharge plans, death and levels of care including long term placements as assigned.
Acts as a liaison among the Medical Staff, various hospital-based disciplines and external agencies.
Ensures continuity of patient’s care and effective communication among the patient’s physicians, caregivers and external agents.
Communicates with medical staff to review recommendations, policies and action regarding problem areas.
Identifies educational needs within the organization about discharge planning, managed care, resource conservation and facilities educational programs to meet these needs.
Promotes quality patient care and effective use of resources.
Consistently demonstrates an ability to assess a situation from a variety of perspectives, consider several alternatives, and choose an appropriate course of action.
Pursues opportunities to improve patient care and resolve identified issues or problems.
Recognizes continued need for containment of costs without jeopardizing quality of patient care.
Obtains and analyzes all pertinent information available to make the most informed decision based on factual and objective data.
Develops, in collaboration with other health care providers, pathways/guidelines/protocols for care of patients.
Uses initiative and good judgment to reach quality decisions.
Assists the Utilization Review (UR) Committee activities; coordinates activities as assigned.
Prepares information on denials for UR discussions and recommendations.
Prepares charts for review of length of stay, level of care, and necessity of admission.
Assures that minutes are kept and information disseminated appropriately regarding committee decisions when assigned.
Refers all cases where Length of Stay and/or acuity designation is questioned to the UR Committee or UR Physician designee.
Assists in review and update of Medical Center UR Plan annually to comply with the law.
NON-ESSENTIAL FUNCTIONS
Performs related and miscellaneous duties as assigned.
