RN-Utilization Review/Case Manage Nurse - RFT

JOB TITLE: UTILIZATION REVIEW/CASE MANAGEMENT – Nurse

DEPARTMENT: CASE MANAGEMENT (QUALITY)

HOURS & SHIFT REQUIREMENTS: Full time position. Hybrid (combination of in person and remote considered)

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

• 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.
• Monitors review on all patient admissions to determine the appropriateness of hospitalization.
• Collects and records necessary information of admission for review.
• 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.
• Conduct appropriate reviews and discusses payer criteria and issues on a case-by-case basis with clinical staff.
• Demonstrates working knowledge of contractual arrangements and fiscal accountability as it relates to appropriate application of Utilization Management program.
• 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.
• 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.
• Initiate and facilitate referral for home health, hospice, durable medical equipment & supplies, nursing home placement, and Swing Bed placement & provides accurate documentation.
• Maintains knowledge of current trends and developments by reading literature and attending appropriate seminars, inservices, or conferences.
• Facilitates discharge planning and interdisciplinary healthcare conferences to communicate potential discharge needs.
• 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.
• Maintains confidentiality of patient information and patient privacy.
• Other duties as assigned.