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The nurse integrates the functions of utilization review, discharge planning, and recourse management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated recourses. The hospitals' utilization review plan and discharge planning procedures outline a collaborative practice to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes.

Job Summary:Works with the interdisciplinary team with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while providing timely and accurate information for the hospital. The nurse integrates the functions of utilization review, discharge planning, and recourse management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated recourses. The hospitals' utilization review plan and discharge planning procedures outline a collaborative practice to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes. The Registered Nurse is responsible for team collaboration for continued compliance with CMS Conditions of Participation regarding the Utilization Review and Discharge Planning as Case Management.Essential Duties and Responsibilities:<ul><li>Promote the missions, vision, and values of the organization.</li><li>Adheres to Simply the Best Standards of Performance.</li><li>Attend and communicate during team meetings that foster interdepartmental collaboration as it pertains to utilization review and discharge planning. Knowledgeable of criteria for Medicare, Medicaid, and private insurance coverage.</li><li>Communicate with PRMC personnel regarding admissions and discharges to various units, in regard to patient stay status updates.</li><li>Communicate as needed with the patient and the patient's family to assess as needed for discharge planning needs.</li><li>Knowledgeable of patient's financial status, diagnosis, and discharge needs. Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and length of stay of patients.</li><li>Reviews patients upon admission and refers the case to the facility utilization review committee for review and course of action when the case fails to meet admission standards.</li><li>Compares inpatient medical records to established criteria and confers with medical and nursing personnel and other professional staff to determine legitimacy of treatment and length of stay.</li><li>Abstracts data from records and maintains statistics. Assist as needed with the discharge planning process alongside the Administrative Assistance for Case Management.</li><li>Actively participates in clinical documentation improvement activities.</li><li>Oversight of the discharge planning process and clinician.</li><li>Work with a direct supervisor to ensure targets are met for the annual plan.</li><li>Knowledge of the continuum of care and utilization process.</li></ul>Professional Requirements:<ul><li>Complete annual education requirements.</li><li>Always maintain patient confidentiality.</li><li>Maintain regulatory requirements, including state, federal and local regulations.</li><li>Comply with all organizational policies and standards regarding ethical business practices.</li><li>Communicate the mission, ethics, and goals of the organization.</li><li>Attend regular staff meetings and in-service.</li></ul>Knowledge/Skills/Abilities:<ul><li>Knowledge of nursing services and insurance coverage preferred.</li><li>Strong organizational and interpersonal skills.</li><li>Ability to determine an appropriate course of action in more complex situations.</li><li>Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude.</li><li>Ability to manage multiple and simultaneous responsibilities and to prioritize the scheduling of work.</li><li>Ability to maintain confidentiality of all medical, financial, and legal information.</li><li>Ability to complete work assignments accurately and in a timely manner.</li><li>Ability to handle difficult situations involving patients, physicians, or others in a professional manner.</li></ul>Education/Training:Licensed as Registered Nurse;Associate degree (A.A.) or equivalent from a two-year college or technical school; Preferred one-year related experience and/or training.BLS required.Benefits/Compensation:We offer a competitive salary and a comprehensive fringe benefits package, commensurate with experience.<ul><li>Health Insurance: Medical, dental, vision coverage.</li><li>401(K) Retirement Plan.</li><li>Paid Time Off (PTO).</li><li>Tuition Reimbursement.</li><li>Flexible Spending Accounts (FSA).</li></ul>

Pratt Regional Medical Center

RN - Case Manager

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RN - Case ManagerPratt Regional Medical Center

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