RN CASE MANAGER- UTILIZATION REVIEW 37

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 health plan.  Evaluates 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 agree 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 patients condition. 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.  Evaluates the effectiveness and appropriateness of care/services and makes 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 meeting 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 appropriate level of care/utilization issues. ER Case Manager  Evaluates 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 resource 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 worker.  Serves as the liaison for the other members of the interdisciplinary team to ensure appropriate and expedient referral upon 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 required. Current BLS required due at time of hire. *Proof of all required License(s) and Certifications(s) REQUIREMENTS Professional Certification in accordance with Case Management requirements preferred. Bi-lingual English/Spanish preferred EXPERIENCE  Minimum of five (3) years acute hospital nursing experience and previous Case Management experience preferred.  Computer literate; proficiency in Microsoft Word, Excel and PowerPoint preferred.  Ability to abstract data from medical records, enter into a Case Management software system. SKILLS  Performs daily documentation of Avoidable/Denied days and Support/Utilization Management entries in Morrisey.  Documents appropriately, all assessments, interventions and plans on Case Management forms per departmental policy; maintaining interdisciplinary communication.  Documents outcomes of all family and interdisciplinary conferences in the appropriate place per departmental policy.  Demonstrates ability to apply Milliman Criteria.  Tracks and monitors inappropriate resource utilization. Identifies under and over utilization, discusses with MD, and educates MD regarding Milliman Criteria.  Monitors performance of vendors.  Utilizes home care and community resources when it is cost-effective alternative to hospitalization.  Provides relevant information to third-party payors and review agencies per departmental policies in a timely manner.  Ensures coordination, integration and management of pertinent information through critical thinking and decision making.  Based on job knowledge, able to direct and manage clinical situations through understanding of roles.  Demonstrates understanding of the patients condition, and changed in condition, by classifying the patient according to stability levels.  Demonstrates analytical skills by using decision making authority and scientific knowledge in order to implement action plans.  Ability to work with diverse patient and staff populations with knowledge and sensitivity to cultural and spiritual influences impacting on patient care  Exhibit a positive attitude  Perform other job related duties as assigned by the Manager of Case Management/Social Services ER Case Manager Skills  Advises and /or collaborates with physicians regarding appropriateness of admission as necessary.  Applies knowledge of the Milliman criteria for hospital admissions and discharge from the Emergency Department  Ensures that requirements with respect to ER admissions are continuously monitored, and that any deviations from established guidelines are identified and addressed with the appropriate physician or ER Medical Director  Locates appropriate home health, nursing home and other community resources for patients to be discharged from the ER. Coordinates discharge arrangements with all involved.  Performs initial discharge planning assessments, anticipates discharge needs, and makes appropriate referrals. Documents a discharge planning assessment of patients in accordance with established Administrative Standards  Communicates inhibiting psychosocial and economic factors

Experience: Minimum 2 Years

Job Family: Healthcare Practitioners and Technical Occupations

Occupations: Registered Nurses

Degree Required: Associate/Diploma Or Higher