Summary:

Provides care management and care coordination for patients receiving treatment and follow up as needed.  Serves in an expanded health care role to collaborate with other clinicians and members of the healthcare team as necessary to ensure the delivery of efficient and cost effective healthcare services.  Uses Ciper tools to identify and intervene in areas of need.  Integrates evidence-based clinical and preventative guidelines in development of patient centered tools to assist patient in decision making that benefits their optimal health.  Provide targeted interventions to avoid unnecessary hospitalizations and emergency room visits.

Requirements:

• Licensure and Certifications: Employee maintains current licensure and/or required certifications. (If 'No' employee is put on leave without pay until in compliance)
• Annual Mandatory Education: Employee completes annual Mandatory Education Module, Annual Health Assessment, Age Specific requirements, etc… (If 'No' employee is put on leave without pay until in compliance)
• Time and Attendance: Employee complies with all HealthAlliance and departmental policies for time and attendance.
• Professional Appearance: Employee complies with HealthAlliance policy for professional Appearance (Dress Code), including wearing ID Badge.
• Safety – maintains a safe environment for patients, visitors, physicians and employees.

Essential Job Responsibilities

    Responsibilities:

• Maintains familiarity with the laws, regulations, and interpretation of utilization review and discharge planning. Remains up to date on changes in regulations, policies and procedures. Monitors the utilization of clinical practice for determining covered cases and length of stay parameters. Incorporates the highest standard of professional, clinical, legal, and ethical practice (i.e., maintains patient confidentiality). Conducts ongoing quality monitoring including identification of quality, risk management and infection control issues and reports them to the Director of the appropriate department. Explores strategies to reduce the length of stay and resource consumption within the case managed populations, implement them and document the results.

• Incorporates knowledge of clinical expertise, quality, insurance and finance into decision making and problem solving regarding patient management. Assesses the patients within the caseload to identify needs, issues, resource, care goals, discharge needs and beyond if necessary. Assesses appropriate level of service and severity of illness using the designated criteria (UR). Performs an initial utilization review for all patients in the caseload within 48 hours from admission and subsequent reviews within 24 hours. Provides utilization review in the Emergency Department as needed. Facilitates a multidisciplinary patient review in concert with RNs on the unit to ensure comprehensive plan of care is followed.

• Plans the patient's care collaboration with the health care team patient/family for the hospital stay. Communicates continually with physicians, providing information and interpretation of third party payer guidelines and assists in securing timely referrals to achieve clinical, utilization and financial objectives. Confers with the attending physician to determine medical necessary for admission or continued stay, when necessary. Secures physician input for reviews on a daily basis in cases of potential utilization denials. Convenes and chairs multidisciplinary care conferences for patients readmitted within 30 days for any reason to evaluate the cause and plan/implement corrective actions; for any patient exceeding the designated length of stay threshold. Coordinate the care of patients whose care is at risk from either a clinical or cost perspective. Follows the established procedures in regard to denial of benefit notice and responds to denials in a timely manner.

• Initiates the discharge planning assessment on admission. Coordinates discharge/post discharge activities and plan by assessing patient and available resources, goal setting, planning, implementing maintaining and evaluating discharge needs. Promotes a timely, cost effective, efficient and safe discharge plan to community services including extended care, acute rehabilitation, sub-acute care, long-term care, or home health services. Contacts insurance companies in a timely manner to coordinate discharge plan. Collaborates with other departments within the outside the hospital as necessary (especially admitting, billing office, fiscal, managed care, insurance case managers, finance) and the screeners.

• Works as part of fluid team to collaboratively meet the needs of patient population and healthcare organization.

• Able to adapt to changing workflow as projects arise.

Education:

• RN, Graduate of an accredited school of Nursing or BSW/CSW (BSW minimum) or Masters in another health related field. Preferred: RN with BSN or CSW

Experience:

• 2 years hospital based. Knowledge of medical/surgical cases. One (l) year QA/UR or Case Management preferred. Current knowledge of Federal and State regulations.

Training/License:

• PRI certification preferred.

Other:

• Clinical competency; excellent verbal and written communication skills; strong organizational skills.