Case Manager/Utilization Review RN

4 weeks ago

Pasco, United States Lourdes Health Full time
Job Description

Education & Qualifications:



  • Graduate from an accredited school of nursing (RN) required, bachelors preferred.
  • Knowledge and skills necessary to provide care appropriate to the population served in the CM Department.
  • Two (2) or more year’s clinical experience preferred.
  • Acute care or community social agency case management experience preferred.
  • Utilization Review experience, preferred.
  • Must possess good assessment, intervention, and problem solving skills. Must be able to address the physical, cognitive, emotional, financial, and psychosocial capabilities of the patient/family. Able to develop and maintain collaborative and professional relationships with multiple stakeholders (patient/family, nursing staff, physicians, payers, and external agencies). Ability to understand medical terminology and principles. Ability to communicate effectively and efficiently, verbally and in writing. Basic computer skills (Outlook, Word, Excel, and databases) are a must. Ability to meet required deadlines while maintaining expected quality. Good organizational skills, with the ability to establish priorities and switch focus with frequent interruptions.
  • Required Certification: Case Management Certification (CCM), preferred.
  • Required License: Current state RN license or Multistate licensure with the authority to work in WA
  • Other: Bilingual and/or English-Spanish speaking abilities preferred. Ability to work with culturally diverse populations.

Responsibilities



  • Case Management: work in conjunction with the medical team in developing best discharge plan available and understanding patient/family needs and wants with safe appropriate collaboration between all parties
  • Educate patients, families and others on all aspects of discharge planning
  • Responsible for the coordination and implementation of case management strategies pursuant to the Case Management Plan
  • Utilization Review: review charts for appropriate levels of care and or continued stay
  • Works with physicians and insurance companies to best manage patients and their stays
  • Utilization Review Management Processes
  • Review clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate
  • Responsible for authorization of appropriate services for continued stay and through discharge
  • Report to work on time and as scheduled; complete work within designated timelines
  • Demonstrates the ability to adhere to the mission, ethics and goals of Lourdes Health
  • Establish effective rapport with other employee’s, professional support service staff, customers, patients, families, and physicians
  • Use effective relationship management, coordination of services, resource management, education, patient advocacy, and related interventions to:
  • Promote improved quality of care and/or life
  • Promote cost effective medical outcomes
  • Prevent hospitalization when possible and appropriate
  • Promote decreased lengths of hospital stays when appropriate
  • Prevent complications in patients under our care when possible
  • Provide for continuity of care
  • Assure appropriate levels of care are received by patients
  • Identifies barriers/variances to discharge for any patient who will unlikely meet anticipated discharge
  • Enters into Abstracting UR/Nurse Doc UR screen
  • Prioritizes case reviews daily based on: Time limits for outpatients in on the unit, Medical necessity determination for continuing stay for patients and Insurance reviews required
  • Marks continuing stay category on UR Nurse Doc program quick interventions or resource mobilization that can assist in meeting LOS targets for non-medically necessary variances
  • When patient situation reviewed suggest potential LOS or quality of care issues involving physicians or care team omissions, commissions or lack of action (when variances are identified), works with Care Coordination Services leadership for determination of need for further review and referral
  • On a prioritized case basis, conducts an assessment of the case situation to identify complex issues or dynamics involving care, treatment or discharge
  • Recommend with nursing leadership, that a case conference be held to problem-solve complex issues related to care, treatment, discharge, or decision-making
  • May coordinate, participate in and/or assist leading of care conferences
  • Work in coordination with the entire medical team to move cases towards a safe discharge
  • Determines need for and recommends changes in level of care and location of care based on defined standards and judgment
  • Consults as necessary with physician (s), patient/family, nursing staff, third party reviewers, and other disciplines regarding realistic clinical outcomes balanced with financial considerations
  • Reviews nursing assessment as to patients home needs, self-care, safety, nutrition, financial status, transportation, family-community support etc.
  • Document findings and recommendations from the above in the NUR module as to no needs expressed by the patient and or family, or needs that were addressed and discharge plan to suffice those needs if within our scope, or to whom referred and contact information
  • Review discharge instructions with patient to include but not limited to; follow-up appointment, medications ready at pharmacy at time of discharge, go over educational tools that we have to send home with patient (ex: CHF)
  • Confers with leadership as needed about resource options for patients and families
  • Cross train to and perform other UR processes as time and needs require
  • Determines with Risk Management staffs and/or Medical Staff Offices’ Manager when cases may require review by Risk Management, Medical Staff Services, or other related leadership staff due to concerns about safety, practice, and resource use, decision-making
  • Provides case assessment and referrals to community resources and hospital resources out of the ED
  • Performs other work as delegated in coordination of UR, Case Management needs

Lourdes Health Network is a Catholic healthcare institution, founded in 1916 by the Sisters of St. Joseph.  Our Mission is an extension of the healing ministry of Jesus.  We are called to serve our community, our patients, their loved ones, and our co-workers with respect, compassion, and care.  We respond to the healthcare needs of the community in a Christian spirit.  We strive for excellence in all we do.

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