Bachelors degree in Nursing, Business, or Health related field preferred. RN license required. Five years experience in clinical nursing. A minimum of two years of recent experience in acute clinical, utilization review, or case management within the last 10 years. National certification preferred within 3 years of hire. Computer knowledge to include Windows, Word, Excel, and database systems. Ability to analyze trends based on decision support systems. Business management skills to include, but not limited to, cost/benefit analysis, negotiation, & cost containment. Knowledge of regulatory requirements inclusive of NCQA, CMS, JCAHO, DOI, HSD. Knowledge in referral coordination to community & private/public resources.
Primary Job Functions
- Identifies and advocates for patients and members in caseload, referring to appropriate inpatient, outpatient and community resources including care coordination.
- Conducts an in-depth assessment which includes, psychosocial, physical, medical, environmental and financial parameters. Collaborates with Healthcare team to proactively develop, implement and document treatment and discharge plan with appropriate resources to address social, physical, mental, emotional, spiritual and supportive needs.
- Collaboratively formulates, implements, coordinates, monitors, and evaluates strategies with the healthcare team to address care management issues for specific patients and disease processes.
- Applies utilization review criteria to assess and document the appropriateness of admission, continued stay, level of care, and readiness for discharge; refers cases that do not meet criteria to designated Physician Advisor. Promotes the appropriate use of clinical and financial resources in order to improve quality of care and patient/member satisfaction.
- Performs cost-benefit analyses and negotiates rates with providers and vendors. Interfaces and negotiates with insurance companies and other payers to ensure payment for services. Generates reports, which demonstrate efficacy through direct cost-savings and outcome measures.
- Actively participates in the development of clinical guidelines and pathways and incorporates processes into the role of nurse care coordinators.
- Educates providers and other PHS/PHP departments on health management strategies and care coordination services.
- Ensure that quality of patient and member cares is maintained or surpassed by collecting and analyzing quality indicators.
- Facilitates and leads patient and member care conferences.
- Performs other functions as required.
Presbyterian Healthcare Services - 2 years ago