Roosevelt General Hospital

Job Summary 

Provides, coordinates and facilitates patient discharge planning in collaboration with other health care professionals during hospitalization, ED visits and/or clinic visits. Assist with organizing services across provider lines, between people, and systems to affect optimal patient outcomes, achieve continuity of care and reduce costs. Serve as a utilization management resource to determine appropriateness of admission, level of care and continued stay.

Essential Functions

• Promote the mission, vision, and values of the organization.

• Identifies patients for teaching, discharge, and extended care facility needs.

• Collaborates with physicians, caregivers, patient, family, other departmental team members, and payor to proactively develop and implement a safe and appropriate discharge plan.

• Participates in team meetings that foster interdepartmental collaboration with the patient and their family as deemed necessary, this includes multidisciplinary meetings and Utilization Review/Case Management meetings. Provides input in such meetings regarding utilization management and discharge planning.

• Applies utilization review criteria to assess and document the appropriateness of admission, continued stay, level of care, and readiness for discharge; refers cases that do not meet criteria to Case Management Director and /or Medical Staff.

• Maintains working knowledge of Medicare, Medicaid and private insurance company coverage for referred products and services.

• Communicate daily with admissions personnel regarding admissions and discharges to various facilities.

• Ensures that a quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting the data to the appropriate department; reports and identifies data that indicates potential areas for improvement of care and services provided within the system.

• Knowledgeable of patient’s financial status, diagnosis and discharge needs and documents these as an ongoing review.

• Assist as needed with obtaining referrals, prior authorization for Home Health Care, DME, SNF, acute rehab and appointments.

• Maintains a current list of resources for referrals and refers to the appropriate inpatient, outpatient and community resources.

• Participate in and complete discharge assessments, complete follow up phone calls in a timely manner and provide referrals/ data according to the patient’s needs.

• Participate and communicate with the care team in management of the patient through the ACO program and electronic health record meaningful use program.

  
  

   

Non-Essential Functions

• Perform other duties as assigned

  
  

   

Professional Requirements

• Adhere to dress code, appearance is neat and clean.

• Complete annual education requirements.

• Maintain patient confidentiality at all times.

• Report to work on time and as scheduled.

• Wear identification while on duty.

• Maintain regulatory requirements, including all state, federal and local regulations.

• Represent the organization in a positive and professional manner at all times.

• Comply with all organizational policies and standards regarding ethical business practices.

• Communicate the mission, ethics and goals of the organization.

• Participate in performance improvement and continuous quality improvement activities.

• Attend regular staff meetings and in-services.

  
  

   

Qualifications

• Current registered nurse licensure in the state of New Mexico

• Three to five years’ experience in discharge planning and Utilization review preferred.

• Knowledge of Utilization management principles, HCFA guidelines, Swing Bed, home health care, skilled nursing facilities/long term care and durable medical equipment is highly desirable.

  
  

   

Knowledge, Skills, and Abilities 

• Knowledge of nursing services and insurance coverage preferred

• Strong organizational and interpersonal skills

• Ability to determine appropriate course of action in more complex situations

• Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude

• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work

• Ability to maintain confidentiality of all medical, financial, and legal information

• Ability to complete work assignments accurately and in a timely manner

• Ability to communicate effectively, both orally and in writing

• Ability to handle difficult situations involving patients, physicians, or others in a professional manner

  
  

   

Physical Requirements and Environmental Conditions 

• Working irregular hours, on call is not required  

• Physically demanding, high-stress environment

• Exposure to blood and body fluids, communicable diseases, chemicals, radiation, and repetitive motions

• Pushing and pulling heavy objects

• Full range of body motion including handling and lifting patients

• Position requires light to moderate work with 50 pounds maximum weight to lift and carry.

• Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing.