Job Requirements

Minimum Education

• BSN preferred

Minimum Work Experience

• Previous UR/QA experienced required
• 2 years of healthcare experience within the Acute Care, SNF, HHA, Behavioral Health and/or Insurance Industry preferred

Minimum License and Certifications

• Current Massachusetts Registered Nurse License

Required Skills

• Interqual experience or equivalent preferred
• Meditech Expanse experience preferred
• Proficient computer skills required
• Must have effective written, verbal and interpersonal communication skills
• Excellent critical thinking
• Ability to multitask and flexibility essential
• Discharge planning experience as it pertains to the care transitions, referral process, patient preference/choice services, patient & family satisfaction, post discharge follow-up etc.

Functional Demands

Physical Requirements:

Exerts 20 to 50 pounds of force occasionally, and/or up to 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects. Frequently reaches (extending hands and arms in any direction), handles (seizing, holding, grasping, turning, or working with hands), and feels (perceiving attributes of items such as size, shape, temperature or texture by means of fingertips). Occasionally stoops (bending the body downward and forward by bending the spine at the waist), and kneels (bending the legs at knee to come to rest on knee or knees).

Essential Functions:

• Utilization Management- Utilization Review and Care Transitions & Coordination
  Providing clinical information to payers, monitoring length of stay, seeking necessary care authorizations and utilizing the InterQual Program; appealing denials as indicated within a timely fashion.
• Reviews all new admissions and Observation patients within 24 hours of admission against High Risk Screening Criteria and documents outcome within the UM EMR.
• Completes assessments on re-admissions within 30 days including reasoning for re-admission documents findings and provides data to the department for stratifying data.
• Follows-up on lack of documentation for medical necessity, supporting documentation with discipline identified. Track
  and trend opportunities for improvement resulting in late Insurance Reviews, longer lengths of stay; including educating providers to
• Interqual Criteria used for determining Admission or Observation status.
• Completes utilization reviews daily and/or as required by insurer, (concurrent and retro) for medical and/or psychiatric appropriateness according to Hospital's approved criteria timely and efficiently.
• Assesses, intervenes, evaluates and determines level of care to establish accurate admission and/or observation status; demonstrates basic knowledge of DRG reimbursement, evidenced by standardized measures for length of stay and acuity level status designation.
• Demonstrates clinical expertise specific to the issuance of ABN/HINN notice to patients and/or legal significant other and care progression.
• Keeping physician and team informed of status change and documenting status.
• Provides education and information to patient, family and care providers as it pertains to continuing care,
  care management, LOS, re-hospitalization and assure understanding of disease management
• Multidisciplinary Team Rounds-participates in discharge planning rounds daily.
• Works collaboratively with multidisciplinary team to determine each patient's needs concurrently including post-acute care when needed; addresses LOS issues, appropriate leveling of patient status; addresses
  potential needs, resources, referrals for other disciplines etc.
• Quality & Statistical Data: Reviews medical record for abnormal findings,complications, delays and deviations from expected clinical outcomes reports such to Provider and/or Director to maintain an efficient, cost effective episode of care for each patient and documents intervention provided.
• Acquires knowledge to keep up with changes in technology and regulations.
• Utilizes knowledge to redesign systems for improving performance.
• Continuously prioritizes projects, activities, and tasks to ensure deadlines and customer needs are met.
• Assists with preparation of reports/statistics as it pertains to staff specific workflow.
• Denials/Appeal Process: Completes assessment of denial within 1 week providing supporting documentation with outcome of review; documents intervention in the UR EMR section.
• Prepare written appeal letters, termination letters, discharge notices, MOON and IMs when appropriate as per regulatory standards and department policies. Report any variances, trends to director. Submits denials/appeals when completed to the department secretary for processing.
• Discharge Planning:
  Communication: builds rapport and responds to needs of physician, reviewers for managed care plans, healthcare team members, 3rd party payers, outside reviewers and vendors to enhance internal and external customer service satisfaction.
• Responsible for completing nursing sections of the SNF Level of Care forms for Mass Health patients in need of care
  SNF placement, timely and efficiently and other forms assisting in transition of care as identified and collaborates with the social worker. In the event of an emergency, Care Coordinator may complete the form in full and process it to help expedite discharge planning process and length of stay.
• The Discharge Planning Process:
  Completes discharge planning assessments timely, efficiently and completely following regulatory standards and departmental policies assuring appropriate patient flow. Appropriately levels patient for home discharge with or without services or to another type of facility such as a SNF, Acute Rehab etc. Develops coordinates and implements discharge plan on cases assigned with patient and/or family/so caregiver.
• Identifying patient preference and selection choice for HHA/SNF placements having patient preference form checked off and signed/dates by patient and/or so. When plan is in place, notify provider establish and determine anticipated readiness for discharge, keeping patient/family/so informed and documenting such in the EMR. Closes case out using appropriate forms for transition of care communication timely and efficiently.
• The Care Coordinator collaborates with the team to assist the Multidisciplinary Team in providing discharge planning activities to assist in expediting a patient’s discharge as part of the care transitions process. It is the expectation that the Care Coordinator remains current and proficient in the discharge planning process in the event coverage is needed.
• Performs any and all other duties as assigned by director and/or designee.