GENERAL SUMMARY:
Under general direction, integrates cost, quality and utilization to facilitate the admission, continued stay and discharge of the patient. Reviews and evaluates appropriateness of admission or continued stay based on medical necessity. The overall goal of the position is to enhance the quality of patient care and engagement, to promote continuity of care and cost effectiveness through the integration and functions of utilization management, and/or care coordination, discharge planning, and appropriate care transitions. Has accountability for the care coordination and discharge planning of all hospitalized patients.
ESSENTIAL DUTIES:
1. Identifies patients that need care management services (i.e. utilization review; care coordination; and/or discharge/transition planning).
2. Responsible for managing a case load of patients that includes facilitating utilization management, and/or care coordination during the patient's stay, planning and expediting plans for safe and effective discharge and transition to the appropriate level of care and setting needed after hospitalization. Coordinating care by considering all patient's needs.
3. Uses critical thinking and effective judgment to determine alternative courses of care. Judiciously uses tools designed to expedite care while being cost effective. Actively participates in readmission initiatives and strategies to maximize patient flow and appropriate resource utilization. Works collaboratively on processes to provide effective transition for patients utilizing hospital outpatient, observation or inpatient services.
4. May review cases for medical necessity, uses InterQual and/or other UR/UM Committee-approved medical necessity screening criteria, when appropriate. Works collaboratively with departmental, revenue cycle, and clinical appeals staff, physicians, and payers to obtain authorization for care and appropriate reimbursement. Determines and assures appropriate status and level of care. Uses defined resources to guide decisions, including Medical Director Care Management, Physician Advisors, and management staff.
5. Routinely communicates with payers, patients/family caregivers, physicians, the interdisciplinary team, post-acute and community-based care providers to facilitate coordination of care and to enhance a seamless transition from hospital setting to the appropriate alternative level of care.
6. Seeks out information and resources to apply creative problem solving for complex discharge/transition planning, quality of care, and utilization management issues. Provides notification and communication to patients/families regarding coverage for hospital and post-acute services, in accordance with CMS regulations.
7. Documents utilization reviews, utilization management actions, care management assessment(s), care plan, discharge plan, and interventions, according to policies, procedures, and regulatory, contractual, and legal requirements. Acts proactively to see that hospital resources are utilized appropriately.
8. Works collaboratively with other departments to define areas of hospital inefficiency and participates in improvement projects.
STANDARD QUALIFICATIONS
A. Education / Training:Graduate of an accredited school of nursing. Bachelor of Science in Nursing required.
B. Work Experience: Minimum two years' experience in the acute care setting. Preference three to five years' experience in care management, utilization review, home care and/or discharge planning.
C. Certification, Licensure, Registration: Requires a current, unrestricted license to practice as a registered nurse in the State of Michigan. Certification in care management preferred.
D. Other Qualifications: Working knowledge of 3rd party requirements, excellent interpersonal and communication skills. Ability to act in an autonomous, self-directed manner in a fast-paced, ever-changing environment.
NOTE: 3 shifts per 4 weeks with 2 shifts being weekend shifts. Must be flexible to schedulebase onneeds of the department
