Position Purpose:Provides individual case management and coordination of discharge of patients while coordinating transition care services for patients admitted to this service. Conducts utilization reviews to determine if patients are receiving care appropriate to illness,disease process, or condition. Reviews can take place as prospective, concurrent, and retrospective in nature. Essential Functions and Basic Duties:Position Specific Performance Expectations:Patient Care Specific:
- Tracks patient cases from admission to discharge. Ability to identify patients who are likely to suffer adverse health consequences upon discharge, needing coordination of support services ,and follow-up care based on diagnosis and level of acuity.
- Conducts timely evaluations for all patients identified by their physician, patient, nursing, family or friend requests, or discharge planner inquiry as needing discharge planning.
- Ability to develop individualized care plan for patients needing patient care planning support.
- Ability to use critical thinking skills supporting patients in accessing all necessary applicable resources for follow-up care:
- From admission (regardless of status) ensures that patients are pre-qualified for hospital admissions.
- Continued admission (regardless of status) ensures that patients are re-qualified for hospital admissions.
- Conducts appeals on behalf of the patient and family (at time of service and for hospital stay denials).
- Develops discharge plans for patients to the most appropriate plans of care - understands the resources available and advocates for the patient for those resources.
- Understands Lifeline, Transition Care, Swing Bed, Home Health, Hospice, Nursing Home Services, and can discern and explain which resource may be best for a specific patient based on diagnosis and level of acuity.
- Fully understands transitional care and how that service works with a Critical Access Hospital.
- Ability to advocate for patients and negotiate with physician and ancillary staff for patients.
- Ability to advocate for patients with insurance companies and CMS for additional services.
- Expert at InterQual and/or Millimen clinical decision-support criteria.
- Ability to identify patients at risk for abuse, depression, falls, or other conditions. Follows the proper procedures for reporting.
Utilization Review Specific:
- Gathers pertinent clinical information and applies and interprets criteria to ensure medical necessity, covered benefits, participating providers, and appropriate services.
- Advocates that the patient is placed in the appropriate level of care and program.
- Interfaces with program staff to facilitate a smooth transition at the time of transfer or discharge.
- Monitors patient charts and records to evaluate care concurrent with the patient's treatment.
- Reviews treatment plans and status of approvals from insurers.
- Facilitates and coordinates discharge planning and works towards reduction of preventable hospital admissions, re-admissions, etc.
- Works closely with Revenue Cycle Department to ensure the insurance precertification process is complete and to update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.
- Collects and compiles data as required and rendering with applicable hospital policies as well as state and federal guidelines.
- Communicates with clinical care team with any outstanding or concerning findings during utilization review including, but not limited to: failure to meet medical necessity, inappropriate admission status, etc.
- Communicates with providers to obtain any medical record documentation necessary to perform utilization review.
- Documents any UR needs or notes into Electronic Medical Record (EMR).
- Administers or participates in audits of programs to ensure agency compliance on utilization review regulations.
- Performs other duties as assigned.
Organization Wide Performance Expectations:
- Demonstrates 100% commitment to performing according to the CHOICE values of MRH and representing the organization in a positive and professional manner.
- Establishes and maintains effective verbal and written communication and good working relationships with all patients, staff and vendors.
- Adheres to MRH attire/dress code per policies and procedures.
- Utilizes initiative; strives to maintain steady level of productivity; self-motivated; manages activity and time.
- Completes annual education, training, in-service, and licensure/certification requirements; attends departmental and organizational staff meetings or reads meeting minutes.
- Maintains patient confidentiality at all times.
- Reports to work on time as scheduled; completes work within designated timeframes.
- Actively participates in departmental and facility performance improvement and continuous quality improvement activities.
- Strives to uphold regulatory requirements to ensure continual compliance with departmental, hospital, state and federal regulations and policies.
- Follows policies and procedures for infection control, safety, and risk management to ensure a safe environment for patients, public, and staff.
QualificationsMinimum Requirements:
- Must be at least 16 years of age (21 for driving positions).
- Must be able to legally work in the United States.
- Must be able to pass a background check.
- Must be able to pass a drug screen and breath alcohol test (if applicable).
- Must complete employee health meeting.
Required Education/Licensure/Certification:
- Unencumbered Colorado or Compact State RN License, preferred or LPN License
- Masters in Social Work or related field, preferred.
- Current BLS certification (or must be obtained within 90 days).
Experience:
- Minimum two (2) years of experience in an acute care setting, preferred.
Position Classification: Non-exemptCompensation Range: $28.10 to $42.17Benefits: Medical, Dental, Life, Retirement, Paid Time Off