RN II-Case Management/Utilization Review (CNA), Full-Time, Day Shift

Adventist Health

19h•Onsite

About The Position

This position is responsible for assessing the appropriateness of admission status and level of care using InterQual criteria. The role also involves providing discharge planning services, coordinating with patients, families, and community agencies, and collaborating with medical staff to ensure appropriate utilization of hospital resources and expedite high-quality patient care. The job requires knowledge of InterQual criteria and Medicare Conditions of Participation, as well as basic computer skills. This position is represented by CNA.

Requirements

Associate Degree (A.S.) or equivalent: Required
Three-Five years nursing experience in an acute care hospital setting: Required
Current RN license in state of practice: Required
Basic Life Support (BLS) certification from approved vendor per AH policy: Required
Registered Nurse (RN) license in state of practice: Required
Basic Life Support (BLS) certification from approved vendor per AH policy: Required
Basic computer skills, including Word, Excel, Outlook, and navigating the Internet are necessary.

Nice To Haves

Bachelor's Degree in Nursing: Preferred
Recent experience in utilization review, discharge planning, and/or inpatient case management: Preferred
Knowledge of InterQual criteria and Medicare Conditions of Participation preferred.

Responsibilities

Assesses appropriateness of admission status and level of care, using InterQual criteria.
Provides discharge planning services, coordinating with patients, families, and community agencies.
Collaborates with medical staff in assuring appropriate utilization of hospital resources and expediting high quality patient care.
Assists MD in making admission decision regarding observation or inpatient status and payer guidelines.
Reviews patient chart on day of admission or first day after admission for SI/IS.
Completes Advance Directive form as needed.
Identifies need for follow-up case management and documents opportunities for intervention based on chart review, multi-disciplinary referrals or MD orders.
Coordinates team or family conferences to ensure timely responses to needs.
Pro-actively assists in development of patient care and teaching plan.
Completes InterQual reviews and reviews care and progress on assigned patients as often as necessary but no less than every 72 hours and documents progress in the computer system and patient chart.
Moves patients through the system based on level of need and is responsive to any need which interferes with the plan of care.
Issues HABN letters as needed.
Refers cases that do not meet InterQual criteria to the UR advisor.
Obtains optimal coverage for patients by furnishing appropriate medical information to insurance carriers and governmental agencies.
Serves as liaison between payers, MD, patients, families and financial counselor.
Collaborates with appropriate team members to maximize re-imbursement through essential documentation.
Documents authorizations/denials in computer system when received.
Is proactive in discussions with MD regarding appropriate inpatient testing.
Anticipates discharge needs and makes appropriate suggestions for referrals linking the patient and family to resources within and outside the health care delivery system and/or community.
Ensures patient is medically stable for discharge and patient and family is prepared educationally, emotionally and functionally for discharge.
Coordinates transfer of patients to other facilities in a timely manner.
Provides accurate documentation in patient record and hospital computer system to reflect CM needs, goals and planned interventions.
Performs other job-related duties as assigned.