Job Description

Job Description

Evaluates and assesses of patients admitted to the Hospital.

Job Responsibility

• * Performs concurrent review on all patients and share all problematic cases with the Supervisor and Physician Advisor.
• * Determines and makes appropriate referrals concerning alternate level of care.
• * Processes adverse determination decision to Physician Advisor and distributes notification, as appropriate.
• * Identifies problematic care patterns or cases and make referrals to the Supervisor and the department involved.
• * Performs retrospective reviews as required.
• * Participates in the maintenance of Utilization Management, Discharge Planning and Case Management statistics as required.
• * Keeps abreast of all changes in policies and procedures relating to Utilization Management, Discharge Planning and Case Management process.
• * Attends Utilization Management Committee and other staff meetings, as required.
• * Participates, as required, in ALC meetings.
• * Participates in Interdisciplinary Patient Care Rounds.
• * Identifies services or treatments that may not be medically necessary and make referrals to the Physician Advisor.
• * Consults with physicians and other health care professionals on aspects of patient care.
• * Makes referrals to other hospital departments for collaboration and assistance in discharge planning.
• * Implements a discharge plan as necessary; document ongoing discharge planning activities in the patients medical record according to protocol.
• * Schedules family/patient conferences with the interdisciplinary team, as needed, to assist in coordinating a safe and timely discharge plan.
• * Collaborates with appropriate professional personnel to assess patients for alternative level of care and notify appropriate hospital departments.
• * Refers patients who require institutional placement to the Social Work Department for follow up and action.
• * Acts as a liaison with patients insurance carrier (case manager, utilization reviewer) to coordinate post hospital services and referrals.
• * Makes arrangement for non-North Shore-Long Island Jewish Home Care services including home care, Hospice, equipment, supplies and laboratory services for post discharge needs.
• * Arranges for patients post hospital needs, i.e. visiting nurse, physical therapy, medical/social model day care, personal care aides, Long Term Home Health Care Programs, home health aides, private hire, DME (equipment, supplies, and respiratory needs).
• * Assists in identifying patient incidents through the NYPORTS program.
• * Performs any and all related duties as required.
• * Performs Clinical Care Coordination assessment within 72 hours of admission on all patients. Perform ongoing reviews every 48 hours or as necessary.
• * Communicates with physicians to ascertain clarification of documentation to justify severity of illness, intensity of service and quality of patient care.
• * Keeps abreast of all changes in Medicare/Medicaid/Commercial Insurances as it relates to the clinical documentation process, the utilization management process and the case management process.
• * Shares all problematic cases with the Supervisor of CM-CCC.
• * Identifies problematic documentation patterns or cases and make referrals to the appropriate departments, to the Supervisor of CM-CCC and/or the Physician Advisor.
• Performs any and all related duties.

*ADA Essential Functions

Job Qualification

• High School Diploma or equivalent, required. Bachelors Degree in Nursing or related field, preferred.
• Current license to practice as a Registered Professional Nurse in New York State.
• Minimum of two (2) years medical/surgical experience in an acute-care hospital. Experience in utilization management/discharge planning, preferred.

*Additional Salary Detail

The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).