Job Description

JOB SUMMARY

Coordinates and facilitates the discharge plan of care and service of selected patient populations across the continuum of illness, promote effective utilization and monitoring of health care resources, and assumes a leadership role with the interdisciplinary team to achieve optimal clinical, financial, and satisfaction of outcomes. Acts as intermediary between hospital and third-party payors to ensure patients receive appropriate medical services, and the organization receives appropriate and optimal reimbursement, in accordance with regulatory standards.

ESSENTIAL FUNCTIONS

Reviews patient admission data within established timeframes of department, to determine the appropriate level of care in accordance with hospital-sanctioned industry standard criteria and/or other established criteria for other settings across the continuum of care.
Assesses, develops, implements and monitors a comprehensive discharge plan of care through an interdisciplinary team process in conjunction with the patient and family in internal and external settings.
Comprehensively assesses patients’ goals as well as their biophysical, psychosocial, environmental and discharge planning needs and financial status.
Identifies key problems, strengths and resources to be addressed in the discharge plan of care, including needed resources post-discharge. Coordinates and facilitates those services.
Ensures accurate documentation for patient’s continued hospital stay is established and maintained, coordinates necessary changes with attending physician and other team members as necessary to achieve optimal care and reimbursement.
Communicates proactively and adeptly with members of the interdisciplinary team to ensure hospital and community resources are appropriately and effectively utilized on behalf of patients and their families.
Facilitates interdisciplinary team meetings to improve quality, decrease cost and improve patient satisfaction.
Coordinates documentation and clarifies necessary details with Patient Financial Services to assist in decreasing denials.
Ensures the completion of documentation necessary for utilization assessments and communicates via electronic medical record information needed to justify continued hospitalization. Maintains any applicable care management databases.
Performs concurrent review to determine correct admission status per insurance criteria, including Interqual or other industry standard criteria recognized by Medicare. Monitors and documents variance days, communicates with attending physician and UR Physician Advisor as indicated. Documents outcomes in appropriate locations.
Communicates within designated time frames with third party payers in order to obtain authorizations and resolve payment issues on behalf of patients and families and the organization if applicable.
May assume Palliative Care responsibilities as indicated, including facilitate and coordinate – pain and symptom management, POLST, family meetings, comfort care.
Performs other duties as assigned.

QUALIFICATIONS - Required Unless Otherwise Stated

EDUCATION:

Graduate of an accredited school of nursing
BSN or MSN preferred.

EXPERIENCE/TRAINING:

Minimum of three years of clinical nursing experience in an acute care hospital or equivalent skilled nursing facility, outpatient case management, home health or hospice experience may be considered
Utilization management/quality management experience preferred.
Third party reimbursement knowledge preferred.

LICENSE/CERTIFICATION:

Current WA State Registered Nurse licensure
Current BLS (Basic Life Support) certification required at date of hire.
Specialty Certification preferred.

KNOWLEDGE/SKILLS/ABILITIES:

Interpersonal skills to obtain and interpret information appropriate to patients’ needs and age as required for assessment range of treatment, and patient care.
Skill and proficiency in applying highly technical principles, concepts, and techniques. Such proficiency is usually acquired through completion of a bachelor’s degree in nursing; any equivalent combination of education, training, and/or experience that fulfills the requirements of the position will be considered.
Demonstrated ability to promote positive interpersonal relationships and patient/family centered work environment.
Basic computer skills including MS Office applications
Effective prioritization skills

LONGVIEW PHYSICAL/COGNITIVE REQUIREMENTS:

Work requires normal amounts of physical effort at least 33% of the time.
Ability to lift objects weighing 80 lbs. or less.
Work requires frequent exposure to minor cold, heat, poor ventilation or sharp instruments. Reasonably anticipated exposure to blood and body fluids once per month or more.
Duties require the ability to concentrate and pay close attention to detail (more than 65% of work time).

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