Case Manager/Utilization Review RN

Tuba City Regional Health Care • Tuba City, AZ

111d

About The Position

Incumbent serves as an Outpatient/Inpatient Case Manager/Utilization Review Registered Nurse (CM/UR RN) for TCRHCC and is responsible for direct supervision and supportive contact for the specific group of identified patient assignments and high-risk patients. The CM/UR RN is responsible for designing and managing a continuum of care focusing on empowering clients to achieve demonstrable outcomes and self-sufficiency. The CM/UR RN is responsible for assessment, service planning, and resource acquisition, monitoring progress and initiating and responding to emerging client needs. The CM/UR RN performs Utilization Review and Management/Clinical Documentation Chart Reviews of patients in the acute clinical care setting, ambulatory care setting and will conduct UR reviews as required. The CM/UR RN will work closely with the Social Work (MSW) Case Manager on Discharge Planning and Care Transitions. The CM/UR RN will work closely with the Physician Advisor and participate on the UR Committee as well as conduct Clinical Documentation Chart Reviews related to peer review, financial or insurance determination, or claims denials. The CM/UR RN will link the client with Community Social Service providers, health care providers, substance abuse, and mental health providers to achieve specific goals. The CM/UR RN will have experience working with culturally diverse low-income populations having multiple barriers to self-sufficiency such as: illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues. The CM/UR RN will work with a multidisciplinary team within the service delivery setting. The CM/UR RN will be committed to Case Management Services and have some collaboration with Purchased and Referred Care (PRC) formally known as Contract Health Services, providing assistance with the PRC Case Specialist. The CM/UR is responsible for compliance with CMS Conditions of Participation regarding Utilization Review and Discharge Planning including implementation and annual review of the Utilization Management Plan and assisting with the coordination of the Utilization Management Committee. The CM/UR is also responsible for ensuring compliance with the Joint Commission and Federal and state regulatory bodies, provisions of care regarding discharge planning and patient needs for care, treatment, and services after discharge or transfer are met. The CM/UR follows the hospital's Case Management/Utilization Program that integrates the functions of utilization review, discharge planning, and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated resources.

Requirements

• Education: Associates Degree in Nursing, must obtain bachelor's in nursing within two (2) years of hire
• License/Certification: A valid, current, full and unrestricted Professional Nursing License to practice as a Registered Nurse (RN) in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
• Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association (AHA) throughout employment
• Experience: Three (3) years of clinical nursing experience performing direct patient care with at least 2 years in an Inpatient setting on a medical-surgical unit, PACU, or higher acuity Inpatient unit (ICU, Step-Down, Telemetry, etc.) or home health (direct care)
• Demonstrate knowledge of the case management, purchased referred care and utilization review
• Demonstrate knowledge of electronic health record systems

Nice To Haves

• A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers
• All employment references must address and indicate success in each one of the following areas: Positive working relationships with others, Possession of high ethical standards and no history of complaints, Reliable and dependable; reports to work as scheduled without excessive absences, Effective verbal & written communication skills, Team management focus promoting a positive and pro-active approach to problem resolution
• Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
• Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC

Responsibilities

• Adheres to most current ACMA Case Management Standards of Practice and Scope of Services
• Adheres to ANA Nursing Scope and Standards of Practice
• Adheres to most current ANA The Code of Ethics for Nurses
• Coordination of service specific assessments, service planning and enrollment
• Works with all facets of the Case Management continuum, i.e., social support, alternate resources, community referrals, discharge planning, Nursing Home/Skilled Nursing Placement and resource utilization
• Comprehensive and client centered service planning and coordination
• Works proactively with the established RN Case Managers/ Social Workers of TCRHCC as a team member for care coordination of the patient populations served by TCRHCC
• Resource acquisition facilitated referrals and linkages
• Consistent and on-going case consultation with all direct service providers
• Developing and maintaining internal and external resource relationship
• Service monitoring and following up to ensure continuity of care and updating of the client service plan
• Identifies patient through consultation and high-risk diagnoses, i.e. COPD, CHF, DM
• Assists with the development of department reports, policy/procedures manuals, and program objectives
• Assists with special projects and reports as assigned
• Conducts system and procedural efficiency evaluation to determine progress, performance, and conformity with program requirements
• Follow up outside inpatient case management referrals for continued follow up, I.E., appointments and PHN referrals
• Will provide case management coverage for the inpatient units and case management referral follow up for the outpatient clinics
• Will prioritize TCRHCC/SPHC outpatient/inpatient case management based upon referrals from providers within the TCRHCC/SPHC healthcare delivery system and high-risk assessment conducted on inpatient population
• Will provide a consistent and on-going collaboration through communication with service providers
• Facilitates appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record
• Improves the overall quality and completeness of clinical documentation by performing admission/continued stay clinical reviews using clinical documentation enhancement guidelines for selected patient populations
• Reviews clinical issues as needed with the coding staff to assign a working DRG to reflect any changes in patient status and procedures/treatments and confers with the physician to finalize diagnoses
• Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and clarified with the physician have been recorded in the patient's chart
• Participates in review and analysis of monthly data relating to clinical quality documentation and insurance medical necessity criteria
• The incumbent will perform UR coordination functions by ensuring medical necessity of preadmission, admission, continued stay, cost containment and discharge planning on patients admitted TCRHCC.

What This Job Offers

• Education Level: Associate degree
• Number of Employees: 1,001-5,000 employees