Applies InterQual Level of Care and/or Milliman criteria to all admissions to determine the

appropriateness of admission and the level of care (e.g., critical care, observation).

Works with admitting physician, the admitting department, and nursing

personnel to ensure appropriate bed assignment for admitted and transferred

patients.

Collects and documents objective data from patient record to support admission or level of

care decisions.

nitiates a case management plan and discharge planning activities at time of the first

admission review, and updates it based on patient’s progress and needs.

In consultation with a patient’s physician, establishes a targeted discharge date at time of the

admission review (This is also known as an estimated length of stay or ELOS). Documents

and communicates this targeted discharge date to the patient’s family, nursing and the multidisciplinary

team via established processes.

Uses clinical knowledge and defined standards of care to proactively identify inappropriate

resource consumption and discusses with attending physician. Refer appropriate cases to

physician advisor for review, as appropriate.

Understand third party payers and current BRMC contractual agreements. Completes and

communicates admission and concurrent review information to 3rd party payors. Document

all payer contact and denial.

 Documents and transmits (through a defined process) appropriate patient-level information to

other unit-based case managers and/or discharge planners to ensure timely and accurate

continuation of case management services when patient is transferred within the hospital.

 Monitors daily progress, including vital signs, resolution of signs and symptoms related to a

procedure, complications, medications, fluids, pain,

Meets with family/patient and communicates plan of care at time of assessment, and as

appropriate throughout admission. Documents interaction and plan of care in medical record.

Initiates referrals to appropriate departments and services within and outside the hospital.

Serves as a liaison between the hospital and other facilities, home health and community

agencies, and makes arrangements as needed for equipment and other required items to be

available at the time of discharge.

Monitors patient’s progress against BRMC-approved medical necessity guidelines, and

evidence-based pathways/protocols. Identifies variances from standards or guidelines of care,

and actively engages physician for decision making and intervention.

Collects variance and delay data at time of occurrence (e.g., avoidable days, delays) for use by

the department and organization.

Provides notice of termination of benefits (TOB) and level of care (LOC) changes to individual

patients and/or representative and other applicable parties on a timely basis.

Uses data and information on a daily basis to prioritize and drive work effort.

Leads multi-disciplinary rounds on a daily basis. Works to ensure that all department are

accountable in coordinating efforts to achieve timely and appropriate patient care.

.Assumes responsibility for continuing education/professional development related to area of

practice. Obtains continuing education in relevant topics as necessary for professional growth.

Participates in department and hospital Performance/Quality Improvement activities, as

assigned.

Keeps statistics and records as required.

 Assumes additional responsibilities as delegated by the Director of the Department..

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BASIC COMPETENCIES

Education:

Current NJ licensure as RN required. BSN or Bachelor’s degree in related field preferred. Minimum 2

years general clinical hospital experience required.

Certification in Case Management (CCM) preferred upon hire or to be obtained within one year of hire.

Experience:

3-5 years of Utilization Review or Case Management experience preferred in acute care settings.

Previous InterQual experience preferred.

Behavior Health experience with knowledge of emergency room admission criteria. desirable

Must have current experience in Behavioral Health with knowledge of emergency room admission

criteria.

Experience in a Long Term Care setting and working knowledge of Medicare Skilled Nursing Program

and Medicare requirements desirable..

Skills:

Excellent verbal and written communication skills.

Ability to lead multi-disciplinary planning and decision making sessions.

Critical thinking/problem solving skills.

Expertise with medical and multi disciplinary practices and/or standards of care for selected diagnosis or conditions

Good interpersonal skills.

Speaks, reads and writes English to the extent required by the position