Clinical Resource Manager

Trinity Health • Boise, ID

5d • Onsite

About The Position

Provides hospital case management, utilization review, and discharge planning in collaboration with patients, families, physicians, and the health care team. Determines level-of-care needs beyond acute care, supports informed decision-making, manages expectations, and coordinates smooth transitions to the next level of care and services. Integrates social services into patient care as appropriate and coordinates hospital case management, utilization review, and discharge-planning activities. Supports quality patient care and regulatory compliance while assisting physicians and other clinical team members in coordinating services for assigned patients. Uses real-time communication with physicians, nursing, and ancillary caregivers to establish treatment, cost, and transition targets and facilitate transition planning.

The role reviews assigned cases for medical necessity and status, conducts concurrent medical-record reviews using established criteria, monitors and adjusts transition plans, and helps coordinate discharge and post-hospital services. It also provides education to health care team members, advocates for patients and families, documents assessments and interventions in Power Chart, and participates in multidisciplinary rounds and department activities.

Requirements

• Current Idaho RN license.
• Nurses moving to Idaho from another compact state must apply for licensure by endorsement and update Idaho as their primary state of residence within 60 days of hire.
• All colleagues must provide licensure or proof of application for a secondary state within 90 days of hire.
• Bachelor of Science in Nursing (BSN) required.
• At least 2 years of varied hospital clinical experience required.

Nice To Haves

• Master’s degree preferred.
• Experience in case management, home health, and/or the insurance industry preferred.

Responsibilities

• Demonstrate the Organization’s Mission, Vision, and Values in behaviors, practices, and decisions.
• Provide competent care-related support for assigned age groups, as applicable.
• Ensure accuracy of documentation for services and supplies provided to patients.
• Coordinate social services and case management functions with hospital departments, external organizations, agencies, and health care facilities throughout care, discharge, and home planning.
• Screen and assess physician-assigned cases for medical necessity, status determinations, and transition needs; reassess and modify transition plans as appropriate.
• Conduct concurrent medical-record reviews using established medical-necessity criteria to determine the appropriate level of care for acute patients.
• Assist physicians with transfer and discharge orders and maintain knowledge of applicable federal, state, and private-agency review requirements and regulations.
• Educate health care team members, including physicians, about requirements for meeting regulatory standards.
• Promote effective and efficient use of clinical resources from admission through discharge.
• Initiate and present denial letters when appropriate; complete PASRRs for skilled nursing facility admissions; deliver Condition Code 44 letters and explain Medicare benefits to patients.
• Research and coordinate patient resources, including medication-assistance applications, Medicaid-pending processes, and equipment from outside facilities for patients with limited funding.
• Communicate regularly with physicians and build effective working relationships to support appropriate costs, cases, and patient outcomes.
• Introduce the clinical resource manager role to patients and families and explain how to contact the manager.
• Advocate for patients and support patients’ and families’ ability to make informed decisions.
• Participate in multidisciplinary rounds or conferences to review treatment goals, optimize resource utilization, provide family education, and identify post-hospital needs.
• Use physician-advisor referrals as appropriate.
• Follow the department’s process for reviewing 30-day readmissions and adhere to the patient-choice policy.
• Document primary and backup plans and communications with patients, families, and the care team; record patient-specific interventions in Power Chart.
• Participate in department staff meetings and subteams.
• Ensure discharge planning complies with Medicare Conditions of Participation and Joint Commission standards.

Benefits

• Competitive compensation.
• Full benefits package.
• Opportunities for career growth and development throughout Saint Alphonsus Health System and Trinity Health.

What This Job Offers

• Job Type: Part-time
• Career Level: Mid Level