SUMMARY: Coordinates the patient's care and service delivery across the health care continuum. Facilitates and insures the achievement of quality clinical and appropriate utilization of hospital resources. Address|
es and resolves patterns in variances that have a negative quality/cost impact.
ESSENTIAL DUTIES AND RESPONSIBILITIES: Includes the following: Other duties may be assigned. The patient population would include:
The Neonate Patient
The Pediatric Patient
The Adolescent Patient
The Young - Middle Aged Adult Patient
The Geriatric Patient
Identifies appropriate patients for ongoing case management through referrals from hospital and medical staff or individual case finding.
Performs concurrent or retrospective review functions for appropriateness of admission and continued hospital stay on every admission.
Analyzes treatment plans and alternatives, formulates the most appropriate plan for the continuum of care, and coordinates the activities of professional staff, agencies, suppliers and family members in achieving planned outcomes.
Develops, implements, monitors, and modifies the plan of care for the patient through a collaborative and interdisciplinary team approach.
Assists and collaborates with the healthcare team in locating community resources and linking patients to the most appropriate agencies, facilities, etc. Makes referrals to Social Service when appropriate.
Functions as a resource for physicians, nursing, and ancillary staff concerning estimated length of stay, avoidable hospital days, and discharge planning needs.
Facilitates discharge planning efforts through early identification. Ensures that each discharge has attainable goals and that all elements of the patient's needs are addressed in the plan.
Assesses the patient's physical, psychological, functional, social, environmental and financial status and goals.
Monitors the patient's progress towards outcomes and makes recommendations as to the continuation of services.
Coordinates assigned multidisciplinary care conference
Tracks and reports trends of inappropriate resource utilization
Assists in data gathering and analysis and makes recommendations for process improvements. Participates and supports CQI projects throughout the institution.
Maintains a current working knowledge of third party payor guidelines and review criteria. Keeps abreast of current regulatory requirements for utilization management, Medicare, Medicaid, and Ohio Key PRO.
Assumes responsibility for own professional growth.
Performs additional duties as assigned within the scope of responsibility.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE:
Graduate of an accredited school of nursing or social work. Bachelor degree preferred. Minimum of three (3) years clinical experience and two (2) years case management/utilization review experience.
Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of mangers, clients, customers, and the general public.
CERTIFICATES, LICENSES, REGISTRATIONS:
Current license as Registered Nurse or Social Worker in the State of Ohio.
OTHER SKILLS AND ABILITIES:
Requires the ability to communicate effectively. Must have basic computer literacy. Effective decision making capabilities. Ability to work in a highly stressful environment. Ability to coordinate various activities simultaneously.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.