Assesses and plans for care that effectively manages the adult and geriatric patient. Performs utilization review for medical necessity with established severity of illness/intensity of service criteria to determine appropriateness of admission, continued stay level of service, and discharge indicators. Evaluates and implements appropriate discharge planning designed to meet individual patient and family needs.
1.Implements appropriate case management services to meet patient/family/significant other needs related to continued care, discharge planning, finances, etc.
2.Demonstrates that outcomes of patient care are within the appropriate length of stay, facilitates appropriate/effective utilization of resources, and ensures that established standards are met through collaboration with the inter-disciplinary healthcare team and the patient/family/significant other.
3.Makes appropriate referrals to physician advisor when documented care does not reflect defined criteria (Severity of Illness/Intensity of Service) per specific payor.
4.Conducts a systematic discharge planning assessment of all patients on admission. Assesses all required elements of discharge planning as required by regulatory and accrediting bodies.
5.Works with Coding Specialist in the assignment and reassignment of DRGs as necessary.
6.Leads and documents inter-disciplinary team meeting weekly making appropriate referrals as indicated to address patient needs.
7.Communicates to appropriate referral sources to assist in discharge planning and ensures completion of patient consent/provider choice documentation.
8.Assists in facilitating and implementing physician orders to aid in the timely completion of patient care across the continuum.
9.Administers and conducts Patient Perception Survey process.
10.Identifies and reports opportunities to improve care for patients in the organization, including patient complaint management and any unusual patient care issues.
11.Assesses all patient care documentation for utilization review monitoring for medical necessity severity of illness/intensity of service as required by payor.
12.Coordinates appropriate utilization of resources throughout patient’s hospitalization. Identifies and evaluates for over/under utilization of resources and delays. Identifies areas for improvement.
13.Assists in the development, implementation, and monitoring of organizational performance improvement. Accurately collects data for various case management processes for internal and external benchmarking as indicated.
14.Educates or causes education to occur for patient/family/significant other regarding continuum of care resources, effective and efficient use of equipment and supplies, and community resources available.
15.Submits appropriate clinical documentation to coder for assignment of a working DRG following the admission of a patient.
16.Updates Coding Specialist on changes to patients’ conditions that may affect DRG assignments.
17.Facilitates physician queries and subsequent appropriate documentation.
18.Manages patient’s hospital stay to achieve an in the window discharge whenever possible.
19.Performs pre-admission assessments and medical necessity evaluations as well as write admission orders in the absence of the Clinical Marketing Liaison.
20.Perform other duties and responsibilities as assigned.
Must hold current nursing license in the State of Alabama. BSN preferred.
Minimum of three (3) years experience in nursing required. Minimum of two (2) years experience in an acute care hospital setting preferred.