Utilization Management RN - FT Days

jeffersonhealth; Philadelphia (Philadelphia County); On-site; USD 85,000 - 110,000; Full time

Job summary

Jefferson Health in Philadelphia is seeking a Registered Nurse for utilization management to apply medical necessity criteria and determine patient status. You will assist in discharge planning to other levels of care and collaborate with the Case Management team to ensure optimal patient outcomes.

You will refer cases to the Physician Advisor, document findings in the EHR, and participate in multidisciplinary rounds.

Qualifications

• RN with nursing degree and current licensure.
• Experience in case management or discharge planning.
• Knowledge of medical necessity guidelines and payer policies.

Responsibilities

• Apply medical necessity criteria to determine patient status.
• Collaborate with Physician Advisor and multidisciplinary team.
• Document findings in electronic health records per policy.
• Coordinate discharge planning and post-acute care.
• Refer complex cases for review per procedures.

Skills

InterQual and mcg criteria proficiency

Strong interpersonal skills

Ability to prioritize workload

Education

Bachelor's Degree in Nursing

Tools

Electronic Health Records (EHR)

Job description

Number of Positions In Requisition

1

Job Details

Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Wil assist in discharge planning to other levels of care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.

Job Description

Summary

Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Wil assist in discharge planning to other levels of care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.

Job Duties

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
• Collaborates with the Physician Advisor and members of the Multidisciplinary Team to facilitate the Medical Necessity process.
• Applies approved utilization acuity criteria to establish appropriateness of admissions and patient status, and documents findings based on department standards.
• Applies initial DRG for all inpatient admissions and documents appropriately (excluding Jefferson New Jersey).
• Must be proficient with InterQual and mcg criteria and its application. Strong interpersonal relationships.
• Ability to: prioritize workload; collaborate with others to meet multiple deadlines; communicate effectively orally and in writing; work in a team environment, document in electronic health records.
• Knowledge of the medical, social, economic, and other services provided by other departments or facilities, and the ability to integrate these multidisciplinary treatments for optimal patient care.
• Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices.
• Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
• Ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation.
• Refers cases to the Physician Advisor or external Physician Advisor per department procedures which require further review or clarification.
• Applies specific relevant medical necessity criteria for all patients to determine the appropriate patient status.
• Documents appropriate medical necessity criteria level of care guidelines subset. (InterQual)
• Follows departmental procedures for Condition 44 downgrades, including medical record documentation, and informing patient and Case Manager.
• Refers cases without documentation of acute level of care to the Physician Advisor.
• Adheres to organizational policies and procedures, identified third party payer contract utilization management workflows and governmental payer processes.
• Complete a medical necessity review for observation status patients in the E.D. via Patient Status Board, at minimum of every 4 hours to determine if patient status has changed or patient can be discharged.
• Applies initial DRG for all inpatients and document in the Care Advance.
• Completes an initial assessment to assess patient's needs and resources for discharge planning.
• Establishes discharge plan including homecare services, transportation, post-acute facility placements.
• Refers appropriate patients to the E.D. Social Worker for intervention.
• Interface with appropriate Inpatient Case Manager to provide all necessary information.
• Case Management Safety Competencies: Identified patients using the appropriate patient identifiers. Utilizes interdisciplinary collaborative team approach to patient care planning and discharge coordination. Ensures patient medical information is properly communicated to external providers/facilities. Communications discharge plan to patient, family and members of multidisciplinary team. Ensures information is transferred to external providers/facilities.
• Understands the impact of developmental stage on adjustment to illness/trauma. Demonstrates ability to identify adolescent behaviors concerning body image, independence, sexual identity, interference with ability to establish identity, tendency to deny or minimize severity of illness. Allows adult patient to maintain control and involves family in decision-making. Continually considers physical, social and emotional barriers and physical limitations while working with the geriatric patient. Demonstrates understanding of end of life issues.
• assesses and anticipates discharge planning

Minimum Qualifications

• Bachelor's Degree Nursing, required
• 3 years case management experience, discharge planning or utilization management experience required.
• Knowledge of managed care, governmental and third party payers reimbursement.
• Must be proficient with InterQual and mcg criteria and its application. Strong interpersonal relationships.
• Ability to: prioritize workload; collaborate with others to meet multiple deadlines; communicate effectively orally and in writing; work in a team environment, document in electronic health records.
• Knowledge of the medical, social, economic, and other services provided by other departments or facilities, and the ability to integrate these multidisciplinary treatments for optimal patient care.
• Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices.
• Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
• Ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation.
• Refers cases to the Physician Advisor or external Physician Advisor per department procedures which require further review or clarification.
• Applies specific relevant medical necessity criteria for all patients to determine the appropriate patient status.
• Documents appropriate medical necessity criteria level of care guidelines subset. (InterQual)
• Follows departmental procedures for Condition 44 downgrades, including medical record documentation, and informing patient and Case Manager.
• Refers cases without documentation of acute level of care to the Physician Advisor.
• Adheres to organizational policies and procedures, identified third party payer contract utilization management workflows and governmental payer processes.
• Complete a medical necessity review for observation status patients in the E.D. via Patient Status Board, at minimum of every 4 hours to determine if patient status has changed or patient can be discharged.
• Applies initial DRG for all inpatients and document in the Care Advance.
• Completes an initial assessment to assess patient's needs and resources for discharge planning.
• Establishes discharge plan including homecare services, transportation, post-acute facility placements.
• Refers appropriate patients to the E.D. Social Worker for intervention.
• Interface with appropriate Inpatient Case Manager to provide all necessary information.
• Case Management Safety Competencies: Identified patients using the appropriate patient identifiers. Utilizes interdisciplinary collaborative team approach to patient care planning and discharge coordination. Ensures patient medical information is properly communicated to external providers/facilities. Communications discharge plan to patient, family and members of multidisciplinary team. Ensures information is transferred to external providers/facilities.
• Understands the impact of developmental stage on adjustment to illness/trauma. Demonstrates ability to identify adolescent behaviors concerning body image, independence, sexual identity, interference with ability to establish identity, tendency to deny or minimize severity of illness. Allows adult patient to maintain control and involves family in decision-making. Continually considers physical, social and emotional barriers and physical limitations while working with the geriatric patient. Demonstrates understanding of end of life issues.
• assesses and anticipates discharge planning