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).
The salary range for this position is $55.73-$55.73/hour