PURPOSE: The Utilization Review / Case Management Nurse (UR/CM RN) position is established to assist with ensuring the placement and provision of cost-effective health care services. S/he will be accountable for examining and evaluating the appropriateness of the utilization of the Hospital/LTC's levels of care and resources. S/he will use various methods to manage these goals, including written and oral communications, committees, and councils, while working closely with staff in the Health Information Management and Patient Financial Services departments, as well as physicians, nurses, social services, auxiliary staff and South Peninsula Hospital (SPH) Senior Management Team.
NATURE AND SCOPE: This position reports to the Director of QI/ South Peninsula Hospital and works with the CFO and Director of Patient Care Services, respectively. The UR/CM RN assists the CEO, Medical Staff, and Allied Practitioners to meet their obligations to the Board of Directors to provide high-quality, cost-effective health care. S/he will coordinate regularly held UM Meetings with these leaders and an appointed Physician liaison to review Hospital/LTC's performance, processes, patient placement issues, payment updates, and regulatory standards.
ENVIRONMENT: South Peninsula Hospital is a 22 bed Critical Access Hospital and 28 bed Long Term Care, located at the southern end of the Kenai Peninsula. South Peninsula Hospital has an active Medical Staff of 25 members, including five surgeons, and a large consulting staff. The working environment is generally pleasant, clean and well-maintained.
SUPERVISORY ACTIVITIES: This position does not supervise any other position.
RESPONSIBILITIES: The main responsibilities of this position are to perform utilization and case management activities to ensure the provision of safe, timely, efficient, effective, equitable, and cost-effective health care. The UR/CM RN assists in the development of policies, procedures and standards of performance to maintain levels of patient care which is in accordance with state and federal regulations and the requirement of other accrediting bodies. The UR/CM RN must maintain effective working relationships with the customers, fellow employees, management, and the medical staff.
CHALLENGE: The major challenge of this position is to make appropriate determinations regarding coverage and length of stay issues and coordinate necessary actions to assure appropriate and timely reimbursement while insuring quality patient care and maintaining effective working relationships with the physicians and allied health practitioners. S/he must remain up-to-date in the areas of utilization and case management and assist in identifying opportunities to improve patient/residential care and implement necessary changes, as required/directed. Additionally, S/he will assure regulatory standards and evidence-based best practices are met.
KNOWLEDGE AND EXPERIENCE: The position of Utilization Review / Case Management Nurse requires that s/he possess the minimum of a degree in nursing and a current license to practice as a registered nurse in the state of Alaska. A minimum of 3+ years of experience in an acute care hospital setting, with one year of utilization management experience is preferred. Must be certified in Basic Life Saving through the American Heart Association. Effective speaking, listening, presenting, and writing skills are required to communicate with the medical staff and with personnel at all levels. Ability in business math and basic statistical analysis is required for data completion, dashboards analyses and presentation of conclusions with UM Team input/support. The UR/CM RN must have a thorough knowledge of Utilization/Case Management, including, but not limited to: knowledge of regulatory standards and procedures relative to utilization and case management issues including the DRG-based reimbursement system; a thorough knowledge of third party reimbursement and methods of payment by insurance carriers; a basic knowledge of ICD-9/10 coding; and basic knowledge of the functions of all hospital departments. S/he must be computer literate and able to use word processing, spread sheets, data bases and presentation software.
PHYSICAL REQUIREMENTS: The ability to reason, speak, read, define colors and shapes, with basic manual dexterity is essential. Physical demands are moderate and may include sitting for prolonged periods, standing, bending, reaching, walking, stooping and occasional lifting and climbing. Most of the work is indoors.
- Effective verbal and written communication
- Collection and analysis of data
- Maintenance of a high degree of confidentiality
- Computer literate using Microsoft Word, Excel and UM software integrated into the hospital computer network
- Effective skills in the organization and prioritization of work
- Ability to function effectively in an independent setting being thorough, accurate and objective in the generation of reports and/or presentation of materials
- Demonstrate flexibility and be amenable to change
- Exercise good judgment and function effectively in stressful situations
- Demonstrate effective, cooperative people skills
South Peninsula Hospital - 21 months ago
copy to clipboard -