Position Summary: The Clinical Resource Management Nurse is an integral part of the Care Management team whose focus is on performing a timely level of care assessment ideally at the immediate point of entry into the health system to ensure that patients are assigned the most appropriate patient class based on their clinical needs incorporating the judgment of their provider. The Clinical Resource Management Nurse is able to work autonomously and swiftly, managing a high volume of complex cases across all HHC system hospitals.
Position Responsibilities: - Apply standard criteria and guidelines to assist in determining and/or to validate the patient class assigned by the provider.
- Document review and findings as well as any additional information relevant to the case as directed and appropriate.
- Partner with the Emergency Department and/or the Admitting Provider to ensure the patient class assigned is appropriate given the patient's clinical presentation.
- Act as a resource and subject matter expert to the Emergency Department and/or the Admitting Provider on aspects of patient class and level of care determination.
- Escalate cases to designated Physician Advisor resource when assigned level of care is not appropriate and Emergency Department or Admitting Provider is unwilling to consider recommendations for alternative.
- Maintain knowledge of industry standards and regulatory requirements which influence patient class and level of care determinations.
- Provide education sessions to constituency groups as needs are identified and/or as requested.
- Support needs of the department in the event of a critical demand or a decrease in volumes by performing a review of work ques, crafting appeal responses, etc.
- Ensure any information critical to the care and progression of the patient gleaned during the review process is relayed to the Care Manager responsible for the patient.
- Complete assignments to demonstrate expert knowledge of criteria as requested.
- Other duties as assigned.
Qualifications: Education: Registered Nurse is required. BSN in Nursing is preferred
Experience: At least five (5) years of relevant clinical experience. Acute care or managed care utilization review is preferred.
Licensure, Certification, Registration: Current State of Connecticut RN license
Knowledge, Skills and Ability Requirements: - Familiarity with clinical care
- Able to influence and negotiate
- Critical thinking, astute assessment and confident in decision making
- Strong interpersonal and communication skills
- Knowledge of Interqual or equivalent criteria and reimbursement guidelines
