Registered Nurse - Care Coordinator - Utilization Review

Primary Purpose
Establishes and maintains an efficient, cost effective care management process by determining patient financial and medical eligibility, medical necessity, and by developing, implementing and monitoring individual patient plans of care and communicating these plans to patients, families, and Parkland staff to ensure quality patient care throughout the healthcare continuum and compliance with program/Parkland policies and procedures. Responsible for the maintaining the knowledge and skill set related to utilization review, care coordination, performance improvement and professional licensure and certification.

Minimum Specifications

Education

• Must be a graduate of an accredited school of Nursing.

Experience

• Must have two (2) years of hospital or community based patient care nursing, preferably in assigned clinical area.

Equivalent Education and/or Experience

Certification/Registration/Licensure

• Must have current, valid RN license or temporary RN license from the Texas Board of Nursing; or, valid Compact RN license.
• Must have current healthcare provider BLS for Healthcare Providers certification from one of the following:
• American Heart Association
• American Red Cross
• Military Training Network

Required Tests for Placement

Skills or Special Abilities

• Provides care to assigned patient population in accordance with the current State of Texas Nursing Practice Act, established protocols, multidisciplinary plan of care, and clinical area specific standards.
• Must be able to communicate and collaborate effectively with a diverse group of patients, families and healthcare staff.
• Must be able to demonstrate a working knowledge of specific patient populations, and be able to demonstrate knowledge of disease processes affecting this group.
• Must be able to demonstrate a working knowledge of PC operations and the ability to use word processing software in a Windows environment.
• Must be able to demonstrate a working knowledge of the laws and regulations governing Medicare, Medicaid and community-based funding sources.
• Must be self-directed and capable of priority setting and problem solving.
• Must be able to demonstrate patient centered/patient valued behaviors.

Responsibilities

• Conducts assessment of patients on assigned Care Coordination team to develop a case management plan of care. Gathers information from patient, physicians, other pertinent members of the healthcare team. Determines funding sources for patients and potential eligibility if appropriate. Plans and develops specific objectives, goals and actions designed to meet the patient's needs as identified through the assessment process. Utilizes hospital approved review criteria to ensure appropriate bed status. Identifies at-risk populations using approved screening tool and follows established reporting procedures. Ensures appropriate admission status is documented.
• Collaborates with all members of the multidisciplinary team and the patient to implement the plan of care. Monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective. Communicates all financial counseling as appropriate. Addresses and resolves system barriers impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge. Ensures/maintains plan consensus from patient/family, physician, and payer. Serves as patient advocate to secure coverage for needed community services. Mobilizes resources and coordinates the effort to the health care team to achieve a positive patient transition to appropriate next level of care.
• Communicates plan of care to patient and their family providing updates and reassesses the plan of care to determine effectiveness. Completes appropriate coordinator management documentation. Evaluates the plan of care at appropriate intervals to determine effectiveness in meeting outcomes and goals. Works with nursing and other disciplines to ensure that discharge needs, including teaching, are met.
• Collaborates with the healthcare team to identify 'best' practices for achieving patient outcomes. Develops reporting mechanisms to communicate outcomes to physicians and other members of the health care team.
• Responsible for Utilization Management activities for assigned patients. Applies approved utilization criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards. Monitors length of stay (LOS) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas.
• Monitors and addresses outcome variances. Identifies causes of outcome variances and implements actions to improve the variances.
• Seeks the most efficient, cost effective ways to provide appropriate care. Supports cost containment efforts through the recommendation of performance improvement opportunities by the health care team.
• Communicates with Care Management team to facilitate covered-day reimbursement certification and/or authorization for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed.
• Transitions patients through the health care system based upon individual and patient population needs. Directs liaison activities to appropriately integrate the patient into the health care continuum including procuring of services, health promotion and counseling, disease prevention, health education and screening, and community resource linkage.
• Engages in special projects and serves on committees, as assigned.