Job Description

Job Description

This is a Utilization Review position. We review all admissions and continued stay to the hospital for Medical necessity and manage the insurance authorization throughout the stay .

Department: Utilization Management - UH
FTE: 0.05
Casual Pool (as needed)
Shift: Rotating

Position Summary:
Coordinate all systems/services required for an organized, multidisciplinary, patient centered care team approach, and assure quality, cost-effective care for the identified patient population. Manage the course of treatment of patients, coordinating care with physicians, nurses and other staff ensuring quality patient outcomes are achieved within established time frames and with efficient utilization of resources. Conduct initial and ongoing assessments, initiate disease management protocols, determine and manage outcomes, ensure continuity of care through discharge planning, utilization of resources and analysis of variances. Function as a contact person for patient, family, health care team members, community resources and employees as necessary. Ensure adherence to Hospitals and departmental policies and procedures. Patient care assignment may include neonate, pediatric, adolescent, adult and geriatric age groups.

Detailed responsibilities:
* PATIENT CENTERED MED - Adhere to and promote the core expectations of the Patient Centered Medical Home or Patient Centered Specialty Practice as applicable
* IDENTIFICATION - Identify appropriate patients within designated specialty area requiring patient case management interventions by utilizing established procedures including census review, risk screens, and referral
* DATA - Perform assessment, data collection, obtain, review, and analyze information in collaboration with the patient, family, significant others, health care team members, employers, and others as appropriate
* ASSESSMENT - Assess the patient's clinical, psychosocial status and current treatment plans
* NEEDS - Assess the patient/family/significant others needs in relation to the medical diagnosis and treatment and resources; provide treatment options, financial resources, psychosocial needs, and discharge planning in collaboration with appropriate resources
* ORDERS AND REFERRALS - Obtain necessary orders from physicians to initiate home health referrals, home infusion medications and supplies, oxygen and equipment; coordinate referrals for oxygen and equipment
* REPORTS & RECORDS - Maintain computer-based tracking system and compile required reports and records
* COLLABORATION - Develop collaborative relationships with other departments/services and community health care agencies facilitating and supporting quality care in area of clinical expertise; act as a resource on complex patient care activities
* GOALS - Assist the patient, family, significant others to set patient-centered goals for individual patient, family, and significant others in collaboration with physicians, staff RNs and other health care team members
* PLAN OF CARE - Develop comprehensive multidisciplinary plan of care effectively utilizing tools and resources
* DISCHARGE PLANNING - Conduct timely discharge planning by anticipating patient needs in collaboration with physicians, staff RN's, and other health care team members
* VARIANCES - Intervene when variances occur in patient individualized treatment plan
* RESOURCES - Coordinate and evaluate the use of resources and services in a quality-conscious, cost effective manner and collaborate with appropriate providers to ensure effective, quality outcomes
* INTERVENTIONS - Monitor and evaluate short-term and long-term patient responses to interventions in collaboration with quality assurance and utilization review, maintaining interdependent follow-up as necessary
* VARIANCE - Review variance from standardized protocols of care with health care team members and implement resolution strategies
* TREATMENT CONFERENCE - Facilitate and/or participate in conferences providing ongoing evaluation of interdisciplinary dynamics, goals attainment and treatment management
* EDUCATION - Ensure and/or provide instruction to the patient and family based on identified learning needs; assess patient/family knowledge, health status expectations, and locus of control
* INFORMATION - Assist with development of activities and methods to ensure information is articulated and disseminated to appropriate members of the health care team
* CONTINUITY OF CARE - Collaborate with the health care team to ensure continuity of patient care throughout all health care settings; promote effective communication among health care team members including the patient, family, and significant others
* MEETINGS - Participate in team meetings when indicated or as directed
* CARE PLAN - Incorporate recommendations and/or services of interdisciplinary team members in the care plan
* COMMUNICATION - Use interpersonal communication strategies with individuals as well as groups of patients, families, significant others, and staff to achieve expected outcomes and patient/family and health care team satisfaction
* DOCUMENTATION - Provide routine verbal and written documentation for the initial assessment and progress of the patient to other members of the health care team in a timely manner
* ORIENTATION - Participate in orientation, continuing education of staff RN's and other health care team members as appropriate
* QUALITY - Participate in continuous quality improvement activities by evaluating patient care systems that may include standards, protocols, and documentation
* COMMITTEES - Attend meetings and represent department or Hospitals within Hospitals related committees or the community, as assigned by supervisor
* DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
* PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
* PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
* PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
* PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
* PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"
* MEDICATION - (UPC and CPC Only) Administer medication, including IV medication, via the Seven Rights; document and communicate clinical findings
* PATIENT CARE - (UPC and CPC Only) Write treatment plans; coordinate patient drug and procedure activities; administer medication and treatment; provide and coordinate nursing care of assigned patients; may facilitate group therapy and/or education sessions

Education:
Essential:
* Program Graduate
Nonessential:
* Bachelor's Degree
Education specialization:
Essential:
* Nationally Accredited Nursing Graduate
Nonessential:
* Nursing

Experience:
Essential:
1 year directly related experience

Credentials:
Essential:
* RN in NM or as allowed by reciprocal agreement by NM
* CPR for Healthcare/BLS Prov or Prof Rescuers w/in 30 days

Physical Conditions:
Light Work: Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly (Constantly: activity or condition exists 2/3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work. May require walking or standing to a significant degree or requires sitting most of the time but entails pushing and/or pulling of arm or leg controls; and/or may require working at a production rate pace entailing the constant pushing and/or pulling of materials even though the weight of materials is negligible.

Working conditions:
Essential:
* Minor Hazard - physical risks, dirt, dust, fumes, noise

Department: Registered Nurse

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