REGISTERED NURSE (FT) - UTILIZATION REVIEW at Whitfield… · Demopolis

JOB SPECIFICATIONS:

• Licensed as a Registered Nurse required. Pay based on experience.
• Experience in an institutional setting involving some degree of discharge planning activity with a capacity to learn discharge planning and case management within the construct of current operations. Additionally, ideal experience would be that involved in working with a home health agency or experience in a hospital with discharge planning, in order to expedite and manage the case management process.
• Specific institutional knowledge of case management or the capacity to learn on a reasonable and timely basis.
• Must be able to assess, distinguish, report and act upon the physical, social, developmental, and environmental needs of all patients admitted to Whitfield Regional Hospital; and the knowledge to provide age specific healthcare to adults, neonates, adolescents and geriatric patients; where appropriate or necessary.
• The capacity to interface effectively with the medical staff and effect their behavior in regard to the discharge planning process as well as case management and other functions in general. It is absolutely essential to be able to communicate with the medical staff of WRH and to influence and assist them in regard to the discharge planning process.
• Must be able to sit, bend, and move intermittently through the day. Must possess the use of arms, hands, legs, feet, and sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met. Must have personal integrity, flexibility and the ability to work effectively with support personnel.
• Must be able to communicate well on the phone with staff physicians and other personnel.
• Must be able to cope with mental and emotional stress of the position and set the proper example.
• Must possess sight/hearing senses or use prosthetics that will enable these senses to function adequately so that the requirements of this position can be fully met.
• Must function independently, have personal integrity, have flexibility and the ability to work effectively with support personnel.
• Must be in good general health and demonstrate emotional stability.

JOB DUTIES AND RESPONSIBILITIES:

• Follows HIPPA guidelines regarding patient and employee confidentiality.
• Performs admission review on all Medicare, Medicaid and any Commercial Insurance patient who require it on the first workday following admission.
• Performs continued stay review on all financial classifications if required.
• Maintains all necessary records and files determined mandatory or necessary to ensure compliance with all agencies.
• Certifies all Medicaid claims for Patient Accounting Services.
• Expedite the discharge of all patients that may result in increased cost or reduced revenue on an individual and case-managed basis taking into consideration the physical, social development and environmental needs of all patients admitted. Specifically, the goal is to reduce Medicare length of stay, where working directly with the physicians to monitor and track all activities to minimize the likelihood of intensified review and other quality review of the medical staff. This includes age-specific considerations related to adults, neonates, infants, adolescents, and geriatric patients; where appropriate or necessary. Must complete an age specific competency review yearly.
• Perform concurrent coding on Medicare admissions and document a preliminary DRG. Discuss any treatment questions affecting DRG category with specified physicians and update DRG as necessary during patient’s stay.
• Ascertain proper problem reporting in regard to all functional areas including patient advocacy, case management, discharge planning and social service activities while keeping immediate superior informed on a timely basis.
• Perform a patient advocacy function in which a period of time is spent everyday interfacing with patients and visitors to identify any problems and ascertain appropriate follow up and corrective action with the departments and other that have direct area of responsibility. Risk Management/Problems relating to patients-clinical perspective.
• Assist and advise on performance improvement activities related to all financial classifications of the patient that interface with Professional Standards Systems as well as with Social Services, and all functions that directly relate to the expeditious outplacement of Medicare and self-pay patients.
• Monitor and cooperate in utilizing the swing-bed facilities at WRH, in accordance with the intended mission of the program, and optimize review in the area of swing-beds as well as cost minimization in the area of Medicare and self-pay patients.
• Serve as a liaison of communication and coordination with discharge planning at WRH, and also external agencies involved in the continuity of care process (nursing homes, durable medical equipment companies, and home health care).
• To attain/maintain a current working knowledge of CMS Conditions of Participation as they apply to Case Management /Discharge Planning and Social Services.
• To attend workshops/seminars as necessary to increase knowledge and skills in all areas of responsibility.
• To attain/maintain a current working knowledge of Blue Cross/ Blue Shield InterQual admission, continued stay, and discharge criteria and Allscripts software.
• To be thoroughly familiar with InterQual criteria as this applies to Medicare patients and any other patients as appropriate.
• Communicate and work with the medical staff on assuring the most effective and efficient utilization of resources is attained.
• Advise immediate superior of recommendations, when applicable, of utilizing denial notices for admission, continued stay or when the physician does not concur with patient assessment.
• To provide pertinent medical information to extended care facilities or home health agencies on all patients referred.
• To maintain verbal communication with physicians and the patient care team on all services provided to each patient. To complete a discharge summary of services rendered to the patient and/or family which is incorporated into the patient’s medical record.
• To compile a weekly admission and preliminary DRG report of all Medicare patients.
• To perform monthly Performance Improvement studies on the quality of services rendered by the Social Services Department.
• Perform Social Services consults pursuant to family and/or patient need and per physician request.
• Job may require other responsibilities not described in the job responsibilities above. As these responsibilities are deemed necessary for this particular job description by your supervisor, they will be added to the job responsibilities or verbally delegated as needed.