Job Summary: This Utilization Review (UR) Registered Nurse (RN) position supports the Mission of Pipeline Health through the provision of distinctive and compassionate care to our patients. This position is responsible for utilization review, assessment of discharge planning needs and coordination of effective discharge plan. Actively and consistently contributes to department operations and communications, behaves in a manner consistent with the mission, vision, and values of Pipeline Health, upholding standards of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) patient communication.
Essential Functions: - Supervise Licensed Vocational Nurses (LVNs) and UR Assistant in the Utilization Department.
- Performs Initial UR within first business day of encounter and concurrent reviews to assess for medical necessity for hospitalization and continued stay utilizing InterQual Criteria (IC). Refers cases not meeting IC for observation. Inpatient encounter or continued stay to the Physician Advisor (PA) for review. Documents initial and concurrent reviews on review worksheets for Medicare, HMO/PPO, and self-pay cases and on TARS for Medi-Cal cases.
- Provides initial and concurrent reviews to health plans or designated IPA (written or verbal as requested by health plan/IPA). Documents authorization or denial provided by health plan or IPA for hospital encounter in Paragon Clinical Care. Notifies attending physician immediately if acute care encounter is denied.
- Informs attending physician of any limitations of health insurance benefit coverage for hospital care (i.e. emergent care codes for Medi-Cal benefits, any exhausted benefit issues, lack of medical insurance) and facilitates notification of financial counselor for their follow up.
- Identifies charts that have insufficient documentation, treatment plan and/or medical necessity to justify admission or continued stay and communicates with attending physician and/or consultant.
- Plans, develops, assesses, and evaluates care provided to Pipeline Health's Behavioral Health Unit (BHU) patients.
- Collaborates with physicians, other members of the multidisciplinary health care team and patient/family in the development, implementation, and documentation of appropriate, individualized plans of care to ensure continuity, quality, and appropriate resource use, communicating changes as appropriate.
- Recommends alternative levels of care and ensures compliance with federal, state, and local requirements.
- Assesses high risk patients in need of post-hospital care planning.
- Develops and coordinates the implementation of a discharge plan to meet patient's identified needs; communicates the plan to physicians, patient, family/caregivers, staff, and appropriate community agencies.
- Reviews, monitors, evaluates, and coordinates the patient's hospital stay to assure that all appropriate and essential services are delivered timely and efficiently.
- Participates in the Bed Huddles and carries out recommendations congruent with the patient's needs.
- Coordinates the interdisciplinary approach to providing continuity of care, including Utilization management, Transfer coordination, Discharge planning, and obtaining all authorizations/approvals as needed for outside services for patients/families.
- Conducts daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in a variety of settings, including outpatient, emergency room, inpatient and non-CMC facilities.
- Acts as a liaison between in-patient facility and referral facilities/agencies and provides case management to patients referred.
- Refers patients to community resources to meet post hospital needs.
- Coordinates transfer of patients to appropriate facilities; maintains and provides required documentation.
- Adheres to internal and external regulatory and accreditation requirements and compliance guidelines.
- Educates members of the healthcare team concerning their roles and responsibilities in the discharge planning process and appropriate use of resources.
- Provides patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
- Reviews, analyses, and identifies utilization patterns and trends, problems or inappropriate utilization of resources and participates in the collection and analysis of data for special studies, projects, planning, or for routine utilization monitoring activities.
- Coordinates, participates and or facilitates care planning rounds and patient family conferences as needed.
- Assesses discharge planning needs with initial review in collaboration with patients, their family or support systems, physicians and other multidisciplinary team members and coordinates patient's discharge planning needs.
- Identify patients at risk for re-admissions and establish effective discharge plan that includes coordination of community resources such as In-Home Supportive services (IHSS), meals on wheels, community van transportation services, referrals to area/county clinics and scheduling follow-up appointments with primary care physicians as indicated.
- As part of coordination of discharge planning needs, facilitates referrals to other acute care, long term care facilities, community resources, home health agencies (HHA) and durable medical equipment (DME) vendors with appropriate documentation entered in electronic medical record (EMR). Utilizes contracted acute care facilities, skilled nursing facilities (SNF), HHAS and DME vendors as required by delegated health plan or IPA.
- Provides patients/families written resource information on Medicare Certified SNF's and HHA's when the plan is for SNF placement or home with home health. Works closely with the patient and family to coordinate referral to facility or agency of patient's preferred choice.
- Contacts Social Worker at time of initial and/or concurrent review when concerns identified regarding patient's psychosocial or community resource linkage needs, financial issues that could impact that could impact continuum of care on discharge or identified reportable adult/elder/child abuse.
- Actively participate in multidisciplinary team rounds and collaborate with other disciplines to affect an appropriate discharge plan.
- Identifies any delays in services ordered by physician and communicates with appropriate departments or providers to help ensure patient receives services ordered timely at that point.
- Uses clear, concise, professional communication with coworkers, patients, all customers internal and external.
- Uses AIDET in interactions with patients and family members. Utilizes white boards for patient communication.
- Collaborates across disciplines to assist in coordination of patient care, including but not limited to patient transfer, discharge, referrals, and spiritual/psychosocial support needs.
- Acts with a sense of urgency when performing tasks.
- Basic unit/department maintenance such as keeping files, drawers, cabinets free from unnecessary clutter.
- Reports on any equipment and or environmental issues for repair.
- Abides by HIPAA (Health Insurance Portability and Accountability Act) regulations.
- Utilizes SBAR (Situation, Background, Assessment, Recommendation) when communicating with oncoming shift, physician communication and giving report to ancillary or other nursing services.
- Speaks up to stop the line and escalates potential safety events if necessary.
- Completes and attends monthly training assigned.
- May float to other areas of the hospital as needed.
- Other duties as assigned.
Behavioral Standard: - Demonstrates effective clinical skills in assessment of medical necessity for observation and inpatient encounters.
- Demonstrate knowledge and skills necessary in Case Management with an understanding of severity of illness and intensity of care.
- Demonstrate the ability to utilize/apply the general and specialized principles, practices, techniques and methods of Utilization Review, discharge planning or case management.
- Working knowledge of regulatory requirements and accreditation standards (Medicare, Medi-Cal, etc.)
- Treats everyone as their customer; utilizes scripting and other tools to ensure consistency in customer service; Expresses recognition and shows appreciation to others; fully utilizes AIDET principles; responds quickly to handle requests, complaints, and questions; displays a positive attitude.
- Demonstrates the highest level of professionalism, passion and care when interacting with patients, families, physicians, and hospital staff members.
- Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential, embracing ingenuity to service our customers.
Communication/Knowledge: - Provides accurate and timely written and verbal communication of clinical information in a manner that is understood by all involved in the delivery of patient care.
- Wears nametag properly; follows dress code policy; answers phone correctly and promptly; is prepared for meetings; meets deadlines; does not participate in gossip; acts ethically and treats others with respect; respects customer's and co-worker's time; establishes and maintains effective relationships with customers and co-workers.
Collaboration/Teamwork:- Attends staff meetings; follows HIPAA guidelines; follows patient rights policy; complies with the compliance program; demonstrates knowledge of role in a disaster; demonstrates knowledge of fire and fire drill procedures; working knowledge of hospital emergency codes; always utilizes standard precautions in the clinical setting; safely manages the environment of care by demonstrating a working knowledge of the requirements of the: Life Safety program, Utilities Management program, Hazardous Materials program, Emergency Preparedness program, Safety Management program, Medical Equipment Management program, Security Management program.
Qualifications/Experience: - Minimum two (2) years of previous clinical experience in acute care setting.
- Minimum one-year experience as case manager in acute care setting preferred.
- Critical thinking, service excellence and good interpersonal communication skills, ability to read/comprehend written instructions, strong organizational skills, ability to follow verbal instructions, and PC (computer) skills.
- A capacity to learn, synthesize, make critical judgments, work independently, place patients and families first, and collaborate with the team members who are recognized leaders within health care.
