Utilization Review RN – $5,000 Sign-On Bonus

Reports To: Director of Care Transitions

Department: 8411 – Care Transitions

Shift: Full Time Days

Sign-On Bonus: $5,000 Sign-On Bonus

Broad Function:

RN Care Coordinator’s primary responsibility is to facilitate, in collaboration with the health care team, the patients plan of care to ensure that all services are provided in a timely manner and promotes a safe and appropriate discharge plan They will collaborate with social workers, physicians, physical therapists and other members of the health care team to: Improve patient care outcomes, Improve access to care, Decrease healthcare cost, Reduce preventable hospital readmissions, Promote continuity of care and Optimize length of stay. As an advocate for the patient, the RN Care Coordinator assists patients to reach optimal function and health in an appropriate environment that will support their needs. The RN Care Coordinator applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient’s health care needs across the continuum in collaboration with health team members to ensure safe, quality and cost-effective care.

Major Responsibilities:

• Provides nursing case management within the standards of the Nurse Practice Act.
• Uses assessment skills to identify patients with actual or potential health care needs that could require care coordination using established high-risk screening criteria.
• Conducts daily utilization review of medical record documentation to ensure admission protocols are followed and patients receive the highest and most appropriate care for their conditions or illnesses.
• Coordinates care across the continuum (inpatient/outpatient/community) to assure appropriate utilization of clinical and community resources.
• Anticipates future needs and educates or refers to valid sources of information.
• Provides in timely manner accurate and pertinent patient information to assist in patient care decisions and optimum care utilization.
• Works with the physician to monitor trends and records all patient interaction and response to disease, illness, treatment.
• Identifies actual or potential variances in standards of care and system problems that could lead to errors, delays in care, complications or increased cost and tracking avoidable days.
• Implements strategies to mitigate barriers that impact the plan of care.
• In conjunction with the physician, the patient, identified care partner, nursing, social work and other members of the healthcare team to ensure a comprehensive plan of care is established to ensure safe, timely and appropriate discharge plan.
• During the utilization review process ensure timely level of care changes.
• Assist in patient discharge appeals and tracking outcomes.
• Rounds regularly with physicians to establish a plan of care, and to ensure that care is proceeding in an efficient and effective manner. Follow up to ensure that tests and treatments are proceeding efficiently, and that results are available to physicians on a timely basis.
• Determine insurance eligibility for various treatments and treatment programs and educate patients on benefits, services and other resources, including payment options.
• Communicate with patients, physicians and insurance companies to secure successful outcomes and hospitalization coverage.
• Follow case and quality management processes in compliance with regulatory guidelines and company procedures.

Qualifications:

Minimum Position Qualifications:

• Current, valid NYS RN license in good standing.
• Two plus years’ experience in nursing.
• Case Management experience preferred.
• Excellent written and verbal communication, critical thinking, facilitation/coordination, and problem-solving skills.
• Must be able to work proficiently with care management software platforms, electronic medical record and similar types of systems for documentation, patient monitoring, and reporting.
• Knowledge of healthcare delivery systems.
• Ability to work a full-time work schedule with rotating weekends (one per month) with flex days off during the week to accommodate weekend coverage.