JOB SUMMARY

Practices with minimum supervision from another licensed professional and is able to perform the following components of care management according to the Case Management Society of America Standards: assessment, facilitating, planning, advocating,, monitoring, evaluation, and outcomes. In collaboration with all healthcare professionals involved, this position is also able to demonstrate the above components within the following core activities: coordination and service delivery, physical and psychological factors, benefit systems, cost benefit systems, cost benefit analysis, care management concepts and community resources.

The URS facilitates communication and coordinates between all members of the healthcare team involving the patient and family in the decision-making process in order to minimize the fragmentation of the healthcare delivery system.

The URS is a leader in effecting change to improve the quality of patient care and reduce the cost of services on a care by care basis, as applicable.

The URS understands financial implications of care in todays healthcare environment such as (but not limited to): requirements for prior approval by payer; cares which would benefit from alternative care; analysis of necessary medical services for cost containment; healthcare plans for appropriateness; home health/hospice resources; healthcare delivery systems; DRG system; care mix index; managed care and capitation.

The URS responsibilities also include facilitating the admission process for non-elective, emergency inpatient admissions and outpatient observation stays; monitoring observation stays at the end of 23 hours for possible inpatient admission or discharge planning; ensuring that all patients are screened against Interqual or other appropriate criteria and assist the physician in identifying alternative methods of care when criteria are not met. Works closely with the Physician Advisor on cares that do not meet admission criteria or continued stay criteria. Provides simple discharge planning services, such as Home Health and DME referrals and makes referrals to social workers for complex discharge planning. The URS, Complex NCM, CM Screener and PARCC will work in collaboration as a team, to ensure timely provision of services. . The URCS will assist in program development and implementation for specific programs and plans of patient care such as clinical pathway, population specific and disease management initiatives.

The URS will review an average patient care load of 25 patients per day, utilizing InterQual review criteria for medical necessity.

The URS will work closely with the UM Specialist/Analyst to ensure cost-effective care and appropriate utilization of services are delivered based on the patients individualized needs, providing the appropriate level of care.

JOB QUALIFICATIONS

Education: Graduate of an accredited School of Nursing.

Licensure: Current LPN or RN Nursing license in the State of Georgia. BLS CPR required.

Certification: Certification in Care Management is desired

Experience: Three- Five years of nursing experience as an LPN/ RN required, with two years of recent clinical experience preferred. Utilization Review and/or Case Management experience of at least one year is preferred. Experience in current technology/computer skills experience required.

Skills and Personal Qualities:

1.Knowledge of all phases of the nursing process and care management process

2. Must demonstrate clinical knowledge in patient care as well as qualities of sound judgment.

• Skilled in the art of human relations, problem solving and conflict resolution/negotiation.
• Ability to articulate knowledge to others.
• Demonstrates good role model qualities, ability to effectively interpret, implement, and support approved hospital policies, regulations, philosophy, and objectives.
• Is self-directed in maintaining and improving own knowledge in clinical skills as well as cognitive aspects of patient care, nursing theory, current research, and care management.
• Capable of effecting positive change across all departments to improve the quality of patient care and reduce the cost of services.
• Ability to do 1:1 and group teaching.

9. Ability to maintain a strong relationship with the medical staff and work as partners to facilitate his/her practice.

10. Knowledge of Medicare, Medicaid and third-party reimbursement policies and procedures.

11. Knowledge of computer hardware and software applications used in the department.

12. Will lead the medical necessity reviews on all assigned patients, working closely with all members of the Care Management team to ensure open communication regarding patient status, appropriate admissions, and appropriate utilization of resources.

13. Will meet with patients and families as appropriate to communicate status, provide education, or assist in teamwork as applicable based on workload.

PHYSICAL, MENTAL, ENVIRONMENTAL AND WORKING CONDITIONS

Works in a typical acute health care setting with adult, geriatric, newborn, special care nurseries, pediatric patients and families experiencing a wide range of medical and/or surgical problems. Requires flexible work schedule to include weekends, holidays and evening hours as needed to meet patient needs. Requires ability to lift and turn patients. Manual and finger dexterity and eye-hand coordination is necessary. Requires standing and walking for extensive periods of time. Requires corrected vision and hearing to normal range. Requires working under stressful conditions. Requires exposure to communicable diseases or body fluids. Requires working with computers. Requires prolonged periods of time spent on the telephone.