RN Case Manager - Utilization Review

Company: Providence Health & Services
Location: Anchorage
Posted on: June 12, 2021

Job Description:

Providence is calling a Registered Nurse (RN) Case Manager Utilization Review (Case Management and Social Services, Days, 1.0 FTE) to Providence Alaska Medical Center in Anchorage, Alaska. We are a community of caregivers delivering every day on our Mission to provide compassionate care that is accessible for all - especially those who are poor and vulnerable.

Apply Today! Applicants that meet qualifications will receive a text with some additional questions from our Modern Hire system.

In this position you will

• Perform integrated concurrent review to identify quality and utilization issues. Applies admission, continued stay/transfer, and discharge criteria to each patient's case. Interfaces with external review companies and consultants, using advocacy and negotiating skills that address medical necessity and appropriateness of inpatient/outpatient levels of care. Acts as resource for physicians and staff PRN. Assists in management of resources with informational and monitoring tool(s) that support access, confidentiality, assessment, analysis of care and throughput, intervention, efficiencies, and quality of care.

• When assigned to Acute Rehabilitation Unit evaluates identified patients for admission to the acute rehabilitation unit by performing comprehensive assessment of discharge planning needs with the patient and their significant others. Coordinates transfers to acute rehabilitation unit with transferring facility.

• Plan and provide discharge planning and other services to address patient/family needs identified in assessment Formulate a tentative discharge plan and discharge date upon completion of the initial interdisciplinary care conference. Communicates with the patient and/or their significant others, the discharge, plan, as well as significant aspects of the treatment plan. Matches patients with appropriate internal and external resources to meet their ongoing needs, and facilitates application(s) for programs and referrals for special needs. Provides documentation that supports and communicates the plan and progress of care. When applicable, attends weekly rounds with the clinical nurses and the therapists to expand/communicate assessment of patient needs. Attends family conferences to provide input and expert assessment of patient needs Communicates daily with physicians to further expand the patient needs.
• Assist in decreasing liability risk factors for the institution by applying quality screens to medical records and analyzing data for potential risks. Communicates findings to Risk Management, specific individuals, or departments.
• Activate the appeal process upon receipt of a non-qualifying determination. Uses clinical and criteria knowledge to determine if an appeal is warranted. Maintains communication channels with Patient Admissions staff, the patient account department and finance. Uses established procedure to resolve denial-of-payment conflicts.
• Consult, collaborate with, and value team members and other health professionals to plan and assure transfer of timely information, in order to meet patient and family needs in a seamless, safe, and effective process. Initiates, attends, and participates in patient care and inter-disciplinary rounds, conferences, team meetings, and case management/division meetings. Establishes and maintains relationships with community service providers to facilitate the care plan and continuity of care. Uses peer mediation process to advocate for/with patients, families, physicians, community resources, consultants, and peers. Attends family conferences to provide input and expert assessment of patient needs. Communicates daily with physicians to further expand the patient needs. Assists patients and their significant other with execution of the discharge plan including coordination of transportation, home health, respiratory needs, caregivers, and referrals for financial concerns, community resources, therapy equipment and adaptive equipment. . Makes referrals to the Medical Social Worker as per policy and procedure, including suspected abuse or neglect, as well as placement in a nursing home or a skilled nursing facility.
• When applicable (i.e. Acute Rehabilitation Unit assignment) communicates discharge information/plan, assists rehabilitation team in collecting FIM status and pathway status for appropriate databases. Communicates medical plan, code status, tests, procedures and results, family issues regarding emotional and psycho/social needs to team members.

• Evaluate patient's response to plan of care through chart reviews, communication with healthcare team, patient and/or family, and when applicable, assists rehabilitation team with FIM follow-up with patient after discharge and at ninety days.

• Educate, consult for, and learn from the Medical Staff and other health care providers in regards to the fiscal impact of their practice. Partner with physicians for benchmark and best practices.
• Implement care/services that recognize age/diversity specific needs/issues of customers served.
• Adhere to security standards of patient information (i.e. HIPAA mandates).
• As a team member, looks for ways to identify patient, process, system improvements, utilization usage, and readmissions prevention with the use of data analysis and collaboration skills. Participates in case reviews, to promote competencies, problem solving, and patient management, with physicians in meeting our patients' medical and social needs, as well as the organization's systems needs across the continuum. Participates in development and/or revision of policies and procedures related to the acute rehabilitation unit.
• Complete initial and annual Competency Plan for assigned job and department.

Required qualifications for this position include:

• Nursing degree/diploma. All Registered Nurses without a minimum of a Bachelor's degree in Nursing must obtain a Bachelor's degree or higher within 3 years of hire
• Licensed as Registered Nurse in the State of Alaska.
• Maintains mandatory and required certifications.
• Current Basic Life Support (BLS) card must be from American Heart Association (AHA) upon hire.
• Two (2) years clinical nursing experience.

Preferred qualifications for this position include:

• Bachelor's Degree in Nursing.
• Three (3) years clinical nursing experience.
• One (1) year utilization Management-review and Discharge-planning experience

About Case Management

Our dedicated team of Nurse Case Manager's and Social Work professionals work in close collaboration with healthcare team members and providers to assist neonates to geriatric patients and families in making decisions regarding continuity of care. Our team's scope of practice includes utilization review to determine medical necessity and level of care needs.

About Providence Alaska Medical Center

Providence Health & Services Alaska is among nation's best employers for healthy lifestyles! The National Business Group on Health, a non-profit association of large U.S. employers, has honored Providence Alaska for its commitment and dedication to promoting a healthy workplace and encouraging our caregivers (employees) and families to support and maintain healthy lifestyles. Mountain-Pacific Quality Health has awarded Providence Alaska Medical Center with its Quality Achievement Award for high-quality care in the areas of heart attack, heart failure, pneumonia and surgical infection prevention. This is the highest honor awarded by Mountain-Pacific.

As the state's largest hospital, Providence Alaska Medical Center provides full-service, comprehensive care to all Alaskans, a role unmatched by any other in the state. Within our community, you will find top notch ski resorts, kayaking, and wildlife. Enjoying the outdoors is just one of many reasons to live in and explore Alaska!

Keywords: Providence Health & Services, Anchorage , RN Case Manager - Utilization Review, Other , Anchorage, Alaska