Registered Nurse Utilization Management Case Management Emergency Department
Position
Summary:
Responsible for Utilization and Care Management services to the Emergency Center.
Advises providers to determine initial medical necessity and transition planning.
Coordinates services to patient/family to prevent unnecessary admissions.
Engages in care transition activities to support patient health and continuity of care.
Essential Functions and Responsibilities as Assigned:
Performs initial case management /clinical assessment on all patients reviewed in the ED.
Conducts initial review using InterQual, MCG and other tools, assists provider in correct admission status (IP, OBV, OP).
Sends accounts to secondary reviewer as necessary.
Provides guidance to providers and clinical staff regarding documentation requirements needed for medical necessity/patient status to support level of care requested.
Interviews patients, families, and other care providers to obtain information necessary to expedite a coordinated discharge as needed.
Assesses patients that qualify as a readmission, determines reason for return and implements alternative to admission when appropriate.
Completes readmission documentation to support data collection and other metrics.
Identifies potential readmissions and evaluates patient's current illness, labs, diagnostic studies, and treatment.
Documents future discharge needs in EMR for continued communication with ICM UM RN and Care Management staff Assesses if follow up treatment, or care can be provided more appropriately elsewhere.
Evaluates patients for discharge planning needs, identifying current living arrangements and services needed.
Makes referrals to other agencies such as homecare, hospice, primary care, and other services.
Provides information for community resources as needed, (i.
e.
:
Community mental health, social work, meals on wheels etc.
).
Advocates and serves as a resource for patients, families, physicians, and the health system regarding obtaining benefits from insurance carriers, providing financial assistance to patients, and educating about levels of care, quality of care issues and regulatory concerns.
Participates in the development, implementation, evaluation, and ongoing revision of initiatives to improve quality, continuity, and cost-effective care.
Represents ICM Department on various teams and performance improvement activities Performs other duties as assigned.
Required State licensure as a Registered Nurse (RN) Bachelor's degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position Four years of acute hospital care experience Two years utilization and/or case management experience in healthcare regulatory and managed care environments American Case Management Certification (ACM) or obtain certification when eligible as defined by the Association Case Management Association, and maintenance of continuing education requirements Preferred:
Bachelor's degree in nursing Experience in utilization management/case management/clinical documentation, critical care, or patient outcomes/quality management working with InterQual/Milliman/third party payer guidelines Certification in Case Management Certification (ACM or CCM) Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross, or equivalent through the Military Training network (MTN) Recommended Skills Advanced Cardiovascular Life Support (Acls) Basic Life Support Case Management Certified Nurse Practitioner Clinical Works Community Mediation Estimated Salary: $20 to $28 per hour based on qualifications.
Summary:
Responsible for Utilization and Care Management services to the Emergency Center.
Advises providers to determine initial medical necessity and transition planning.
Coordinates services to patient/family to prevent unnecessary admissions.
Engages in care transition activities to support patient health and continuity of care.
Essential Functions and Responsibilities as Assigned:
Performs initial case management /clinical assessment on all patients reviewed in the ED.
Conducts initial review using InterQual, MCG and other tools, assists provider in correct admission status (IP, OBV, OP).
Sends accounts to secondary reviewer as necessary.
Provides guidance to providers and clinical staff regarding documentation requirements needed for medical necessity/patient status to support level of care requested.
Interviews patients, families, and other care providers to obtain information necessary to expedite a coordinated discharge as needed.
Assesses patients that qualify as a readmission, determines reason for return and implements alternative to admission when appropriate.
Completes readmission documentation to support data collection and other metrics.
Identifies potential readmissions and evaluates patient's current illness, labs, diagnostic studies, and treatment.
Documents future discharge needs in EMR for continued communication with ICM UM RN and Care Management staff Assesses if follow up treatment, or care can be provided more appropriately elsewhere.
Evaluates patients for discharge planning needs, identifying current living arrangements and services needed.
Makes referrals to other agencies such as homecare, hospice, primary care, and other services.
Provides information for community resources as needed, (i.
e.
:
Community mental health, social work, meals on wheels etc.
).
Advocates and serves as a resource for patients, families, physicians, and the health system regarding obtaining benefits from insurance carriers, providing financial assistance to patients, and educating about levels of care, quality of care issues and regulatory concerns.
Participates in the development, implementation, evaluation, and ongoing revision of initiatives to improve quality, continuity, and cost-effective care.
Represents ICM Department on various teams and performance improvement activities Performs other duties as assigned.
Required State licensure as a Registered Nurse (RN) Bachelor's degree in nursing from accredited educational institution, or actively pursuing degree and to be obtained within five years of accepting position Four years of acute hospital care experience Two years utilization and/or case management experience in healthcare regulatory and managed care environments American Case Management Certification (ACM) or obtain certification when eligible as defined by the Association Case Management Association, and maintenance of continuing education requirements Preferred:
Bachelor's degree in nursing Experience in utilization management/case management/clinical documentation, critical care, or patient outcomes/quality management working with InterQual/Milliman/third party payer guidelines Certification in Case Management Certification (ACM or CCM) Basic Life Support (BLS) certification as a Healthcare Provider by the American Heart Association, American Red Cross, or equivalent through the Military Training network (MTN) Recommended Skills Advanced Cardiovascular Life Support (Acls) Basic Life Support Case Management Certified Nurse Practitioner Clinical Works Community Mediation Estimated Salary: $20 to $28 per hour based on qualifications.
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