POSITION SUMMARY:
Performs inpatient, outpatient, concurrent admission, and procedure reviews using the standardized level of care criteria selected by the facility to determine necessity, appropriateness, and efficiency of admissions, procedures and extended duration reviews. Obtains authorizations for outpatient and inpatient procedures, inpatient admissions, and observation beds. Obtains retro-authorizations when requested by billing/financial services. Performs appeals for denials and arranges physician peer to peer reviews when appropriate. Promotes good public relations through contacts with physicians, fellow employees and patients in which services are being rendered. Maintains appropriate documentation for all Utilization Review (UR) transactions. Assists Lead UR coordinator (director) with observation, inpatient, and swing bed level of care criteria determination and payor authorizations. Assists Discharge Planning Coordinator (director) with patient care transitions by arranging for prescribed medical alternative treatment or other plans of care, as needed, when the patient is discharged from the hospital to promote continuity of care. Assists patient and their families in decision making regarding providing the best possible level of care with least restrictions of the patient, whether the service provided is to be continued in-home care or out-of-home care setting. Participates in patient care transitions process, including discharge/transfer instruction education of the patient both prior to and after discharge from hospital. Consults with a qualified Social Worker or Certified Case Manager as needed. Assists Swing Bed coordinator (director) with swing bed necessity determinations, authorizations, admissions, and documentation. Assists patient with activities as another modality in the total care plan that specifically address the individual patient problems/needs and help the team meet the care goals for that person. Assists Centralized Scheduler with scheduling duties, as needed, in facilitating the scheduling process for hospital and outpatient patients via scheduling procedures Monday through Friday Days. Obtains essential information for registration, scheduling, and insurance referral. Provides customer service to patients, care providers, and others, through effective, timely communication such as telephone triage, email, and written correspondence. Communicates with a variety of clinical disciplines including physicians, advanced practitioners and nursing staff to clarify medical necessity and to obtain needed information for Payor authorizations. Must be able to work well in fast-paced, continual changing environment, with minimal supervision and ability to problem solve through respectful communication under the direction of the Case Management director. Works throughout hospital with a work area provided in Case Management Office.
Position: Weekend Nurse Case Manager
PRIMARY RESPONSIBILITIES & AUTHORITIES:
- Obtain admission office information on all patients (patient census record), receive admission requests, pre-op schedules, and orders from the admissions office, surgery, and/or physician clinical staff of services to be performed in an observation, inpatient, or swing bed setting.
- Perform admission, concurrent, and retro reviews using the current Level of Care criteria standards selected by the facility and according to criteria developed and approved by LH Critical Access Hospital Guidelines.
- Serve as a Utilization Review and Discharge Planning Resource for members of the medical and hospital staff by the triage of patients to appropriate level of care through discussions with attending physician and nursing staff and by initiating a plan for post-hospitalization of care when indicated.
- Work with the patient/family/caregivers and physician to screen patients and help decide appropriate discharge plans. Then, plan for the need for continuing care assistance, post-hospitalization, and make arrangements/referrals for placement at appropriate agency in skilled, intermediate, personal care, assisted living facilities, and/or care in the home (Home Health, Hospices, etc.), as applicable. Enable patient and their families to understand, accept, and follow medical recommendations through individual or group conferences.
- Receive referrals from physicians, nursing staff, or any other department of the hospital who observes patient needs and discusses with healthcare team members aspects of patients care to assist with planning the best level of care with least restrictions after discharge.
- Evaluate the patient insurance coverage and proposed procedure for the appropriate care setting, contact insurance for authorization of procedure, outpatient or inpatient hospitalizations, and/or swing bed level of care to include but, not limited to, ambulance transfers, etc. and alternative options across the care continuum. Make indicated client referrals.
- Interface with external reviewing/paying agencies regarding review of specific cases for medical necessity and appropriateness.
- Interview patients and/or families in securing background information and evaluating factors significant in providing continued patient care. Perform social assessments for care transitions. Interview patient/family/care givers/primary care provider of the patient to obtain information about living conditions, financial, social, and emotional environments of the patient. Assess the patients psychosocial and spiritual needs and interests.
- Contact community resources, such as senior citizens center and other pertinent sources, such as durable medical equipment companies, in order to mobilize environmental services on the patients behalf.
- Keep patient and/or family members informed of updates regarding transition/discharge plans and provide patient teaching to enable understanding of medical recommendations with an appropriate reading/comprehension level.
- Collaborate and communicate regularly with hospital personnel on progress of continued plan of care and incorporate activity goals and interventions for the identified physical and psychosocial problems. Develop and implement individual and/or small group activities to achieve identified goals congruent with the physicians plan of care, coordinate activities with other patient services, and document the patients response to the plan (i.e. achieving the treatment goals).
- Consult and refer cases for physicians review by providing accurate, complete, and objective information regarding the patients clinical situation and plan of care.
- Follow up call to high-risk and designated patients post hospitalization according to criteria/guidelines implemented at LH to provide problem solving and intervention to prevent potential preventable re-hospitalizations. Maintain responsibility for post hospitalization care plan (discharge instructions) to be provided to after-hospital medical services, including primary care physicians and specialists.
Position: Weekend Nurse Case Manager
- Make adequate, concise entries in the patients Electronic Medical Record in an effort to promote regular communications with physicians, nurses, and other personnel involved in the patients care.
- Schedule appointments accurately and according to the availability of the various departments, as needed.
- Complete pre-registrations including insurance verification, eligibility, and requests referral and pre-certification number from PCP at the time of scheduling the appointment, as needed.
- Coordinate multiple appointments from calls and orders work queues, as needed.
- Reschedule and cancel appointments and communicate as needed with patients/families and departments/clinics, as needed.
- Demonstrate positive customer service when greeting patients, care providers, and others.
- Assure the patient has all the information they need so they will arrive on time and prepared for their procedures and that the hospital has all of the information required to bill properly for its services.
- Provide patient/family accurate service instructions and directions/maps prior to appointment as directed by service department so that all departments may view and print the schedule for the daily appointments, and maintain open communication with hospital departments regarding schedule changes, as needed.
- Secure demographics, guardian and emergency contacts, guarantor, and coverage information, updating registration when patients information changes.
- Develop and maintain good working relationships with other hospital personnel, community health, welfare and social agencies.
- Must have full knowledge and ability to access and assign ICD-10-CM and CPT codes for proper diagnosis and procedures.
- Maintain confidentiality of all information obtained during performance of job duties, as in accordance with HIPPA rules and regulations.
- Assist with maintaining work logs of reviews of admission, procedures, concurrent, and/or retrospective reviews.
- Maintain a clean and well-organized work area.
OTHER DUTIES AND RESPONSIBILITIES:
- Assist the Lead Utilization Review Coordinator (director) with Utilization Review P.I. analysis, as needed.
- Assist the Case Management Director with Quality and Performance Improvement reviews and data collection for analysis, as needed.
- Assist Centralized Scheduler with scheduling duties, as needed.
- Hold and/or attend meetings in Case Management Directors place, as appropriate and needed.
- Other duties and responsibilities as directed by the Case Management Director.
- Meet requirements for CEUs to keep certification current.
- Assist with discharge/transfer process when needed via obtaining necessary documentation and provision of documents (history, progress notes, MAR, labs, etc.) and patient information to complete a seamless patient level of care transition according to policies.
MINIMUM QUALIFICATIONS (EDUCATION, EXPERIENCE, SKILLS, ABILITIES):
Must be a graduate from an accredited school of nursing with a minimum of a Licensed Practical Nurse Licensure or an Associates Degree of Nursing required with experience in utilization management and review functions.
Thorough knowledge of medical terminology, clinical, and surgical data interpretation, medical coding, and patient assessment planning required.
Position: Weekend Nurse Case Manager
Knowledge base of various computer software and use of computers, including keyboarding/typing skills required (i.e. Microsoft Outlook, Excel, and Word).
Excellent communication skills, verbal and written are mandatory. Excellent customer service, problem-solving skills, prioritization, and organization are essential. Must display an ability to build positive relationships with medical staff.
Ability to be thorough, pay close attention to detail, and follow detailed instructions with good time management skills.
OTHER SPECIAL REQUIREMENTS (LICENSES, CERTIFICATIONS, REGISTRATIONS, ETC.)
Must hold and maintain current, valid, and unrestricted Registered Nurse OR Licensed Practical Nurse License through the Kentucky Board of Nursing.
Must have previous experience in healthcare setting.
Membership with a utilization review or case management professional organization is encouraged.
PHYSICAL DEMANDS:
May remain seated for extended periods of time. Use of telephone for long periods of time (earpiece available for use). Some walking required for reviews and errands throughout facility; bending, stretching, and/or lifting may be required. Ability to use hands for typing, taking notes, and messages is required. Interactions with patients and their caregivers/family members will occur.
WORK ENVIRONMENT:
Well lighted, ventilated, and climate-controlled area within the hospital.
May come in contact with body fluids, blood, and various infectious diseases while interacting with patients.
Shared office space with other case management personnel.
May organize outdoor activities, weather permitting.
