Job Description

To perform the activities of Case Management and Utilization Management to facilitate the collaborative approach of the multi-disciplinary team for patients during their episode of care. Reviews and delivers necessary clinical information timely to third party payers with compliance to governmental regulations and insurance guidelines. Reviews for Hospital appropriateness in the correct admission status. Facilitates discharge planning activities with healthcare team while optimizing appropriate length of stay.

Position Requirements

• Must be currently licensed by the State of Tennessee as a Registered Nurse.
• Case Management Certification preferred/required within 3 years of employment
• 5 years Medical Surgical Experience/Case Management/Acute Hospital preferred
• Demonstrated clinical knowledge base in medical/surgical nursing.
• Demonstrated organization, time management, problem solving and critical thinking skills.
• Able to perform independently and in team situations under the supervision of a Director/Manager.
• Demonstrated effective verbal and written communication skills.
• Efficient review and interpretation of the medical record.
• Familiar with Meditech, Care Management, basic computer skills required.
• General knowledge of Governmental and Insurance guidelines related to case management compliance, reimbursement, DRG system and Interqual/MCG Criteria preferred.
• Positive attitude with a willingness to learn new processes and adjusts well to change.
• Required Weekend Rotation
• Office and Clinical environment.
• Possible exposure to airborne pathogens.
• Telephone and computer use for extended periods of time.
• Able to walk/stand, up to 2 hours/day.
• Clear legible handwriting
• Clear understandable voice.

Key Results

• Consistently sets priorities and exhibits efficient time management skills with assigned workload within the confinements of scheduled shift.
• Timely reviews hospital admissions within the guidelines of the UR Plan consistently using appropriate criteria.
• Monitors and Reviews assigned Observation patients at least once daily maintaining an observation rate of = /< 18% (<15%=above expectation).
• Initiates discharge needs assessment on all INPTS within 24 hours of admission, with completion within 24 hours of discharge.
• Consistently facilitates conversations comparing EDD and GMLOS of assigned patients during MDR and encourages proactive discharge planning. (Excluding moms/babies/NICU/PEDS)
• Maintains an average hospital monthly LOS <3.5 days. (=/ < 3 days = Above Expectation)
• Consistently completes pending insurance list by the end of each Friday.
• Timely identification of the Initial and follow-up Important Message Notification for a departmental average of 97% of all Medicare and Medicare Advantage Beneficiaries.
• Consistently Reviews Surgery schedule emails and SDC patients daily for correct procedure/status/authorization, and communicates any changes or discrepancies to appropriate parties preventing reimbursement denials.
• Completes discharge appeals process for Inpatients and ABN delivery for inappropriate outpatient stays as defined by policy.
• Performs within the CAHPS standards regarding "nurses explain in way you understand".
• Performs within the CAHPS standards regarding communication with nurses, as shown on CAHPS standards.