REGISTERED NURSE-Discharge planning

Memorial Regional Health•Craig, CO

11h•$34 - $50

About The Position

This part-time position involves tracking patient cases from admission to discharge, identifying patients at risk for adverse health consequences, and coordinating support services and follow-up care. The role requires developing individualized care plans, advocating for patients with healthcare providers and insurance companies, and ensuring patients are placed in the appropriate level of care. The nurse will also be responsible for managing insurance precertification processes, conducting utilization reviews, and maintaining compliance with hospital policies and state/federal guidelines.

Requirements

Registered Nurse license
Ability to identify patients who are likely to suffer adverse health consequences upon discharge.
Ability to develop an individualized care plan for patients needing patient care planning support.
Ability to use critical thinking skills supporting patients in accessing all necessary applicable resources for follow-up care.
Ability to advocate for patients and negotiate with physicians and ancillary staff for patients.
Ability to advocate for patients with insurance companies and CMS for additional services.
Expertise in InterQual and/or Milliman clinical decision-support criteria.
Ability to identify patients at risk for abuse, depression, falls, or other conditions.
Ability to follow the proper procedures for reporting.
Ability to gather pertinent clinical information and apply and interpret criteria to ensure medical necessity, covered benefits, participating providers, and appropriate services.
Ability to advocate that the patient is placed in the appropriate level of care and program.
Ability to interface with program staff to facilitate a smooth transition at the time of transfer or discharge.
Ability to monitor patient charts and records to evaluate care concurrent with the patient’s treatment.
Ability to review treatment plans and status of approvals from insurers.
Ability to facilitate and coordinate discharge planning.
Ability to work closely with the Revenue Cycle Department to ensure the insurance precertification process is complete and to update the denial log statistics on an ongoing basis.
Ability to collect and compile data as required and render with applicable hospital policies as well as state and federal guidelines.
Ability to communicate with the clinical care team on any outstanding or concerning findings during utilization review.
Ability to communicate with providers to obtain any medical record documentation necessary to perform utilization review.
Ability to document any UR needs or notes into the Electronic Medical Record (EMR).
Ability to administer or participate in audits of programs to ensure agency compliance with utilization review regulations.

Nice To Haves

Understanding of Lifeline, Transition Care, Swing Bed, Home Health, Hospice, Nursing Home Services.
Full understanding of transitional care and how that service works with a Critical Access Hospital.

Responsibilities

Tracks patient cases from admission to discharge.
Identifies patients who are likely to suffer adverse health consequences upon discharge, needing coordination of support services, and follow-up care based on diagnosis and level of acuity.
Conducts timely evaluations for all patients identified as needing discharge planning.
Develops an individualized care plan for patients needing patient care planning support.
Uses critical thinking skills to support patients in accessing all necessary applicable resources for follow-up care.
Ensures patients are "pre-qualified" for hospital admissions from admission.
Ensures patients are "re-qualified" for hospital admissions during continued admission.
Conducts appeals on behalf of the patient and family for hospital stay denials.
Develops discharge plans for patients to the most appropriate plans of care, understanding available resources and advocating for the patient.
Understands various post-discharge resources such as Lifeline, Transition Care, Swing Bed, Home Health, Hospice, and Nursing Home Services, and can explain which resource may be best for a specific patient.
Fully understands transitional care and its integration with a Critical Access Hospital.
Advocates for patients and negotiates with physicians and ancillary staff.
Advocates for patients with insurance companies and CMS for additional services.
Applies and interprets clinical decision-support criteria (InterQual and/or Milliman) to ensure medical necessity, covered benefits, participating providers, and appropriate services.
Identifies patients at risk for abuse, depression, falls, or other conditions and follows proper reporting procedures.
Gathers pertinent clinical information.
Advocates that the patient is placed in the appropriate level of care and program.
Interfaces with program staff to facilitate a smooth transition at the time of transfer or discharge.
Monitors patient charts and records to evaluate care concurrent with the patient’s treatment.
Reviews treatment plans and status of approvals from insurers.
Facilitates and coordinates discharge planning and works towards the reduction of preventable hospital admissions, re-admissions, etc.
Works closely with the Revenue Cycle Department to ensure insurance precertification is complete, updates denial log statistics, and initiates appeals.
Collects and compiles data as required and renders with applicable hospital policies as well as state and federal guidelines.
Communicates with the clinical care team on any outstanding or concerning findings during utilization review.
Communicates with providers to obtain any medical record documentation necessary to perform utilization review.
Documents any UR needs or notes into the Electronic Medical Record (EMR).
Administers or participates in audits of programs to ensure agency compliance with utilization review regulations.
Performs other duties as assigned.