Job Description

FULL TIME - DAYS

Position Purpose:

The individual in this position has overall responsibility for reviewing the clinical plan of care in comparison to evidence-based practice and regulatory requirements. The position integrates care coordination, utilization management, and discharge planning.

The individual’s responsibilities will include, but not limited to the following activities:

a)medical necessity screening

b)care coordination

c)discharge planning

d)facilitating multi-disciplinary patient care conferences

e)managing concurrent disputes of payers about levels of care

f)making appropriate referrals to other departments e.g., nutrition, physical and occupational therapy)

g)participating in weekly Complex Case Reviews

h)arranging for post-discharge patient education

i)clear, complete and concise documentation in case management software and hard copy documents

j)maintaining accuracy of patient demographic and insurance information

k)identifying and documenting potentially avoidable days

l) identifying and reporting over and under utilization.

Position Qualifications:

Current Pennsylvania RN license in good standing.

Bachelor’s degree in nursing or related field preferred.

Minimum of 3 years of clinical nursing experience. Current Acute Care Case Management and/or Utilization Review experience required.

Minimum of one year of Charge nurse experience or related experience required.

Theoretical knowledge of the clinical processes, case management and continuity of care required. Motivation for self direction.

Use of nationally recognized utilization review standards preferred.

General computer knowledge.

Ability to relate and work with chronically ill and disabled patients of all ages and with those with emotional disturbances. Possesses the ability to handle sensitive situations.

Ability to relate to and work with various managed care representatives, defining the continuing need for medical treatment.

Ability to understand and integrate needs of the patient with available resources.

Ability to work closely with physicians and provide guidance regarding clinical guidelines and managed care organization requirements.