RN Case Manager - Utilization Review
Company: Providence Health & Services
Posted on: June 12, 2021
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
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
- 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
- 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
- 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
- Implement care/services that recognize age/diversity specific
needs/issues of customers served.
- Adhere to security standards of patient information (i.e. HIPAA
- 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
- Complete initial and annual Competency Plan for assigned job
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
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
Keywords: Providence Health & Services, Anchorage , RN Case Manager - Utilization Review, Other , Anchorage, Alaska
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