Address
Form of workJob Details
Job Location
Nacogdoches, TX
Qualifications
Graduate of an Accredited School of Nursing. Two (2) years clinical experience. Registered Nurse currently licensed in the State of Texas.
Knowledge of federal and state regulations related to admission criteria, medical terminology, anatomy and physiology, disease process, utilization of services/resources, communication techniques, and hospital procedures.
Skilled in use of telephone, fax, answering machine, adding machine, copier, computer and printer, reading and interpreting medical records. Ability to read and interpret medical records/information on admission and/or within twenty-four (24) working hours of admission when information is provided.
Job Summary
Under the direction of the Director of Utilization Management, this position is responsible for coordinating the medical necessity determination for all inpatients through the ER, outpatient testing as needed and procedures generated through the admissions department, as needed. The primary objective of this position is to operate a system that will enable NMH to maximize accounts receivable cash flow. Also, to provide utilization screening for the purpose of assuring appropriate allocation of resource while striving to provide high-quality patient care in the most cost effective manner. To assist with aspects of discharge planning. Provide and be a resource to all levels of staff for utilization and medical necessity issues. Oversee applicable regulatory compliance, while facilitating a customer focused atmosphere that is consistent with the organization's goals and objectives. This position also supports the physician and interdisciplinary team, in facilitating the patient's care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care. The Case manager will work closely with SW. The Case Manager will provide clinical updates as required to Medicare, Medicaid, private insurances and other payers, to maintain certification for the hospitalization. The Case Manager plans effectively in order to meet patient needs, manage the length of stay, promote efficient utilization of resources and facilitate the patient's journey through the continuum of care.
POSITION STANDARDS:
1. Determines that medical necessity for inpatient or observation status is documented appropriately.
2. Communicates with ER physicians and physicians' offices to determine medical necessity. Obtains records from the physician's office to support medical necessity, if needed, for direct admits.
3. Works with ER physicians and physicians' offices to develop admission processes to facilitate accurate medical necessity and rapid admission procedures.
4. Issues Advanced Beneficiary Notification to patients and notifies their physician when medical necessity regulations mandate.
6. Establishes systems to routinely communicate to staff and inter and intra-department issues that may affect the unit.
9. Educates patients, family, hospital staff, physicians and physician office staff regarding medical necessity process issues and requirements.
10. Knowledge of current registration computer system application.
12. Assists with alternatives to admission from ER i.e. home with home health care.
13. Assists in coordinating the various discharge needs, i.e., communication with family, arranging transfers, referrals, or equipment. Participates in discharge planning documentation within the medical record for those patients under case management.
14. Identifies patients in need of case management through admission screens, discharge planning meetings, or referral.
15. Performs admission, concurrent and focused reviews using evidence based guidelines criteria on all inpatients as required.
16. Reviews all observation admissions twice a day for appropriateness of utilization of services, and to ensure prompt admission or discharge.
17. Performs case management assessment, develops a discharge plan, and facilitates the implementation of that plan.
18. Reassessment of discharge needs in an ongoing manner.
19. Involves the patient and/or family with the discharge planning, from admission.
20. When contacted, assists the physician to identify alternative care settings for cases that do not meet pre-established admission criteria
21. Demonstrates appropriate clinical knowledge to be a resource for physicians in establishing documentation of severity of illness and intensity of services in order to assure that patients are served in the most appropriate care setting.
22. Refers cases that do not meet medical necessity for admission or outpatient services to Physician Advisor after contact with the Attending physician to obtain complete information.
23. Request more information from attending physician when documentation does not reflect need for admission or continued stay in the hospital.
24. Identifies actual and potential delays in service or treatment. Refer to appropriate resource individual, (e.g., attending physician, physician advisor, nurse manager, ancillary department manager).
25. During customary business hours, coordinates outgoing transfers.
26. Communicates effectively with other hospital departments and outside organizations, coordinating the flow of information to assure that medical necessity for admission and continued stay is documented.
27. Returns all third party payor requests within twenty-four working hours, to include initial medical reviews, and updates Monday thru Friday, 8:00 a.m. to 4:30 p.m. Retrospective reviews within forty-eight hours, weekends & holidays.
28. Participate in discharge planning rounds on designated nursing units. Maintain an attendance record of all participants in the unit-based discharge planning meetings.
29. Maintains daily computer or paper record of data obtained from admission, concurrent, and focused reviews.
30. Prepared for the Physician Advisor; knows the information in the record, and has clearly
documented any concerns.
DEPARTMENTAL OR UNIT SPECIFIC:
1. Maintains diplomacy at all times
2. Keeps abreast of new regulations concerning appropriate admission status.
3. Documents medical necessity.
4. Acts as a resource for medical and hospital staff, interpreting TJC, Medicare, Medicaid, and Peer Review Organizations guidelines for reimbursement.
5. Communicates effectively with other hospital staff and outside organizations, coordinating the flow of information to assure that medical necessity for admissions is documented.
7. Assesses severity of illness and intensity of service as needed, on current hospitalized patients.
Communicates with the physician on the appropriate admission status. Verifies documentation
supports admission using evidence based guideline criteria.
Job Location
Nacogdoches, TX
Qualifications
Graduate of an Accredited School of Nursing. Two (2) years clinical experience. Registered Nurse currently licensed in the State of Texas.
Knowledge of federal and state regulations related to admission criteria, medical terminology, anatomy and physiology, disease process, utilization of services/resources, communication techniques, and hospital procedures.
Skilled in use of telephone, fax, answering machine, adding machine, copier, computer and printer, reading and interpreting medical records. Ability to read and interpret medical records/information on admission and/or within twenty-four (24) working hours of admission when information is provided.
Job Summary
Under the direction of the Director of Utilization Management, this position is responsible for coordinating the medical necessity determination for all inpatients through the ER, outpatient testing as needed and procedures generated through the admissions department, as needed. The primary objective of this position is to operate a system that will enable NMH to maximize accounts receivable cash flow. Also, to provide utilization screening for the purpose of assuring appropriate allocation of resource while striving to provide high-quality patient care in the most cost effective manner. To assist with aspects of discharge planning. Provide and be a resource to all levels of staff for utilization and medical necessity issues. Oversee applicable regulatory compliance, while facilitating a customer focused atmosphere that is consistent with the organization's goals and objectives. This position also supports the physician and interdisciplinary team, in facilitating the patient's care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care. The Case manager will work closely with SW. The Case Manager will provide clinical updates as required to Medicare, Medicaid, private insurances and other payers, to maintain certification for the hospitalization. The Case Manager plans effectively in order to meet patient needs, manage the length of stay, promote efficient utilization of resources and facilitate the patient's journey through the continuum of care.
POSITION STANDARDS:
1. Determines that medical necessity for inpatient or observation status is documented appropriately.
2. Communicates with ER physicians and physicians' offices to determine medical necessity. Obtains records from the physician's office to support medical necessity, if needed, for direct admits.
3. Works with ER physicians and physicians' offices to develop admission processes to facilitate accurate medical necessity and rapid admission procedures.
4. Issues Advanced Beneficiary Notification to patients and notifies their physician when medical necessity regulations mandate.
6. Establishes systems to routinely communicate to staff and inter and intra-department issues that may affect the unit.
9. Educates patients, family, hospital staff, physicians and physician office staff regarding medical necessity process issues and requirements.
10. Knowledge of current registration computer system application.
12. Assists with alternatives to admission from ER i.e. home with home health care.
13. Assists in coordinating the various discharge needs, i.e., communication with family, arranging transfers, referrals, or equipment. Participates in discharge planning documentation within the medical record for those patients under case management.
14. Identifies patients in need of case management through admission screens, discharge planning meetings, or referral.
15. Performs admission, concurrent and focused reviews using evidence based guidelines criteria on all inpatients as required.
16. Reviews all observation admissions twice a day for appropriateness of utilization of services, and to ensure prompt admission or discharge.
17. Performs case management assessment, develops a discharge plan, and facilitates the implementation of that plan.
18. Reassessment of discharge needs in an ongoing manner.
19. Involves the patient and/or family with the discharge planning, from admission.
20. When contacted, assists the physician to identify alternative care settings for cases that do not meet pre-established admission criteria
21. Demonstrates appropriate clinical knowledge to be a resource for physicians in establishing documentation of severity of illness and intensity of services in order to assure that patients are served in the most appropriate care setting.
22. Refers cases that do not meet medical necessity for admission or outpatient services to Physician Advisor after contact with the Attending physician to obtain complete information.
23. Request more information from attending physician when documentation does not reflect need for admission or continued stay in the hospital.
24. Identifies actual and potential delays in service or treatment. Refer to appropriate resource individual, (e.g., attending physician, physician advisor, nurse manager, ancillary department manager).
25. During customary business hours, coordinates outgoing transfers.
26. Communicates effectively with other hospital departments and outside organizations, coordinating the flow of information to assure that medical necessity for admission and continued stay is documented.
27. Returns all third party payor requests within twenty-four working hours, to include initial medical reviews, and updates Monday thru Friday, 8:00 a.m. to 4:30 p.m. Retrospective reviews within forty-eight hours, weekends & holidays.
28. Participate in discharge planning rounds on designated nursing units. Maintain an attendance record of all participants in the unit-based discharge planning meetings.
29. Maintains daily computer or paper record of data obtained from admission, concurrent, and focused reviews.
30. Prepared for the Physician Advisor; knows the information in the record, and has clearly
documented any concerns.
DEPARTMENTAL OR UNIT SPECIFIC:
1. Maintains diplomacy at all times
2. Keeps abreast of new regulations concerning appropriate admission status.
3. Documents medical necessity.
4. Acts as a resource for medical and hospital staff, interpreting TJC, Medicare, Medicaid, and Peer Review Organizations guidelines for reimbursement.
5. Communicates effectively with other hospital staff and outside organizations, coordinating the flow of information to assure that medical necessity for admissions is documented.
7. Assesses severity of illness and intensity of service as needed, on current hospitalized patients.
Communicates with the physician on the appropriate admission status. Verifies documentation
supports admission using evidence based guideline criteria.
