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.
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.
Perform other duties as assigned
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.
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
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.
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