RN-Utilization Review/Case Manage Nurse - RFT

JOB TITLE:        UTILIZATION REVIEW/CASE MANAGEMENT – Nurse

DEPARTMENT:    CASE MANAGEMENT (QUALITY)

GENERAL SUMMARY 

The Utilization Review/Case Management Nurse is directly responsible for review of patient admissions for severity of illness and intensity of service to ensure appropriate level of stay and effective discharge planning is provided. Working closely with the Medical Staff and Nursing units in this effort, effective and efficient utilization is accomplished. Additionally, working with multi-disciplinary teams ensures safe transitions of care.

GIBSON AREA HOSPITAL & HEALTH SERVICES MISSION STATEMENT

To provide personalized, professional healthcare services to the residents of the Communities we serve.

PRINCIPLE DUTIES AND RESPONSIBILITIES

1.    Coordinate and facilitate patient progression throughout the continuum to achieve desired outcomes and organizational goals while promoting continuity of care, collaborative practice and appropriate utilization of resources.
2.    Monitors review on all patient admissions to determine the appropriateness of hospitalization.
3.    Collects and records necessary information of admission for review.
4.    Meet with identified patients/families to assess needs and develop an individualized discharge plan, collaborating and communicating with the interdisciplinary team in all phases of the discharge planning process.
5.    Conduct appropriate reviews and discusses payer criteria and issues on a case-by-case basis with clinical staff.
6.    Demonstrates working knowledge of contractual arrangements and fiscal accountability as it relates to appropriate application of Utilization Management program.
7.    Provides concurrent reviews of all admissions to determine change of diagnosis, symptoms, problems, patient condition, treatment scheduled, admission status, barriers to care, and facilitates safe transition to home or extended care facility.
8.    Communicates with variety agencies both governmental and private to facilitate safe transitions of care, provide justification of admission, and provide continued length of stay based on Severity of Illness/Intensity of Service criteria, IntraQual &/or MCG Criteria.
9.    Initiate and facilitate referral for home health, hospice, durable medical equipment & supplies, nursing home placement, and Swing Bed placement & provides accurate documentation.
10.    Maintains knowledge of current trends and developments by reading literature and attending appropriate seminars, inservices, or conferences.
11.    Facilitates discharge planning and interdisciplinary healthcare conferences to communicate potential discharge needs.
12.    Assists and is involved in the Gibson Area Hospital’s continuous quality improvement efforts designed to enhance patient outcomes, increase patient satisfaction, and improve the utilization to the Gibson Area Hospital’s human capital and physical resources.
13.    Maintains confidentiality of patient information and patient privacy.
14.    Other duties as assigned.

PHYSICAL REQUIREMENTS 

1.    Physical strength to perform the following lifting tasks:

•    Floor to waist - 40 pounds
•    14” to waist - 50 pounds
•    Waist to shoulder - 20 pounds
•    Shoulder to overhead - 10 pounds
•    Carry 40 pounds for 30 feet
•    Push 40 pounds/force for 30 feet
•    Pull 40 pounds/force for 10 feet

2.    Work requires the ability to lift and carry files on a daily basis.
3.    Work requires the ability to stand up to one hour at a time.
4.    Work requires communication abilities necessary to assess patient’s condition and interact with physicians and exchange information with care providers and others on a daily basis, including ability to use telephone.
5.    Work requires proofreading and checking documents for accuracy on a daily basis.
6.    Work requires ability to use a keyboard to enter and transform words or data on a daily basis.  Ability to communicate in writing.
7.    Visual acuity necessary to observe patient, obtain information, and use documentation.
8.    Auditory acuity necessary to hear patient/family/staff for the purpose of communication.

REPORTING RELATIONSHIP

Director of Quality and Case Management.
 

EDUCATION, KNOWLEDGE AND ABILITIES REQUIRED

1. Knowledge and skills necessary to provide utilization and case management of patient care units appropriate to the age of the patient served including infant, pediatric, adult, and geriatric.
2. Knowledge of utilization review interventions and overall understanding of compliance with Severity of Illness and Intensity of Service criteria & IntralQual/MCG Criteria.
3. Knowledge of utilization policies, procedures, area of resources, and state and federal regulation.
4. Advanced communication skills are required to interact with patients/families, healthcare providers, and outside agencies.
5. Registered Nurse with at least two years clinical experience preferred.
6. Emotional stability to deal with high stress level associated with working with acutely ill patients and maintaining effective working relationships with peers and physicians.
7. Keen mental functions to perform assessment and decision making skills in the management of utilization of the units in the hospital.
8. BLS certification required.

INFECTION EXPOSURE RISK LEVEL

Category 2- Low Risk

Position contains tasks that involve no exposure to blood, body fluids, or tissue, but employment may require performing unplanned tasks that do involve exposure.

WORKING CONDITIONS

1. Works in a normal office or patient care environments where there are relatively few discomforts due to dust, dirt, noise, and the like.
2. Works with patients and may be exposed to contagious diseases of infectious material, but potential for person harm and injury is limited when proper safety and health precautions and equipment are used.