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SalaryLE0010 InHealth Management, LLC
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MMM Holdings, Inc.
Job Description Inpatient Unit
POSITION: Concurrent Review Nurse (CRN)
Job Description Inpatient Unit
POSITION: Concurrent Review Nurse (CRN)
POSITION DESCRIPTION
Manages the inpatient utilization of healthcare resources and develops, coordinates and implements the discharge plan, to ensure that the coordination and continuity of care results in optimal patient outcomes. Will adhere to the department policies related to the care of the Plans’ SNP members. Staff will attend all required trainings related to the MOC especially in areas of care management, ICP, ICT and health assessments. Staff will notify supervisors of any processes not in compliance with the Plan’s SNP policies and MOC requirements. Clinical staff who do not complete the required annual training may not perform their clinical duties until the training is completes\.
ESSENTIAL DUTIES AND RESPONSIBILITIES
1. Performs daily visits to Acute, SNF, and Rehabilitation Inpatient facilities to concurrently review admissions and continued stay to determine appropriate Utilization, Quality Assurance, Risk Management and Discharge Planning Needs.
2. Validates all Inpatient admissions for appropriate level of care within forty-eight (48) hours of admission on weekdays and within seventy-two (72) hours of admission on weekends.
3. Develops and documents a discharge plan on each Inpatient within forty–eight (48) hours of having performed the first Concurrent Review of notified admission cases.
4. On a daily basis, concurrently reviews all Inpatient care, on site or telephonically to validate appropriateness of services, lengths of stay and levels of care, utilizing nationally recognized Medical Care Guidelines approved by CMS, NCQA and MMM Healthcare, protocols a critical pathway.
5. Develops, monitors, modifies and implements individualized transfer or discharge plans, to assure a timely discharge between levels of care and between facilities.
6. Communicates regularly with the attending Physician/Hospital staffs regarding the patient’s status, any identified problems related to appropriateness of services, quality of care, or issues that may impact a timely discharge.
7. Refers appropriate problems to the Plan’s Medical Director for intervention and resolution and confers daily regarding patient and physician related issues.
8. Performs concurrent quality review and reports identified quality issues to the health plan’s
and hospital’s Quality Improvement Department.
9. Initiates the initial discharge assessment to all admission cases.
10. Initiates referrals to DPU / Ambulatory Care Management and TU utilizing the health plan’s criteria for referrals.
11. Researches community resources available to members, assesses the financial implications of a specific discharge plan, and develops a plan to most appropriately access those resources as well as covered benefits.
12. Identifies aberrant Inpatient days, documents, and codes and reports the data to the Utilization Management Inpatient Coordinator and Inpatient Nurses.
13. Captures required in – patient utilization data and forwards the information, daily, to the Utilization Management Inpatient Coordinator.
14. Prepares and submits to the Health Services Department / UM Medical Care Manager a monthly report of activities performed.
15. Attends all Utilization Management staff meetings and actively participates bi-monthly or monthly MSO IPAs Regional’s meetings.
16. Daily concurrent and retrospective review documentation process in corporative electronically application in accordance with NCQA and CMS regulations to assure compliance standards and federal regulations utilizing established medical care guidelines.
17. Performs additional duties, weekly reports and/or relevant to the position as requested by the Health Services Department Inpatient Medical Care Manager.
18. Documents the discharge data in the Daily Census module MedHOK application of MMM/PMC.
19. Collaborates and participates in all regional CRNs hospitals routes task forces to perform close cases on daily basis.
20. Ensure, performs and follows the quality of services according to CMS, NCQA regulations and corporate processes and policies.
21. Responsible on business day hours connected and attend regional conference calls with CRN Supervisor and Regional AIMDs by planned phone calls, following the department established processes according on daily basis.
22. Participates on applications upgrades, testing and/or new tools implementations.
23. Performs additional job-related duties or special task as assigned by appointed CRNs Supervisor or Manager.
24. CRN will be updating the primary and secondary Diagnosis to developed reports for the Model of Care to assure the adequacy to ensure quality report.
25. Determinates necessity of services for Authorizations of Planned and Unplanned Transitions of Alternate Level of Care from acute admission and/or sub-acute Hospitals Discharges, including the outpatient admissions requests to Skill Nursing Facilities and/or Rehabilitation Centers.
2. Validates all Inpatient admissions for appropriate level of care within forty-eight (48) hours of admission on weekdays and within seventy-two (72) hours of admission on weekends.
3. Develops and documents a discharge plan on each Inpatient within forty–eight (48) hours of having performed the first Concurrent Review of notified admission cases.
4. On a daily basis, concurrently reviews all Inpatient care, on site or telephonically to validate appropriateness of services, lengths of stay and levels of care, utilizing nationally recognized Medical Care Guidelines approved by CMS, NCQA and MMM Healthcare, protocols a critical pathway.
5. Develops, monitors, modifies and implements individualized transfer or discharge plans, to assure a timely discharge between levels of care and between facilities.
6. Communicates regularly with the attending Physician/Hospital staffs regarding the patient’s status, any identified problems related to appropriateness of services, quality of care, or issues that may impact a timely discharge.
7. Refers appropriate problems to the Plan’s Medical Director for intervention and resolution and confers daily regarding patient and physician related issues.
8. Performs concurrent quality review and reports identified quality issues to the health plan’s
and hospital’s Quality Improvement Department.
9. Initiates the initial discharge assessment to all admission cases.
10. Initiates referrals to DPU / Ambulatory Care Management and TU utilizing the health plan’s criteria for referrals.
11. Researches community resources available to members, assesses the financial implications of a specific discharge plan, and develops a plan to most appropriately access those resources as well as covered benefits.
12. Identifies aberrant Inpatient days, documents, and codes and reports the data to the Utilization Management Inpatient Coordinator and Inpatient Nurses.
13. Captures required in – patient utilization data and forwards the information, daily, to the Utilization Management Inpatient Coordinator.
14. Prepares and submits to the Health Services Department / UM Medical Care Manager a monthly report of activities performed.
15. Attends all Utilization Management staff meetings and actively participates bi-monthly or monthly MSO IPAs Regional’s meetings.
16. Daily concurrent and retrospective review documentation process in corporative electronically application in accordance with NCQA and CMS regulations to assure compliance standards and federal regulations utilizing established medical care guidelines.
17. Performs additional duties, weekly reports and/or relevant to the position as requested by the Health Services Department Inpatient Medical Care Manager.
18. Documents the discharge data in the Daily Census module MedHOK application of MMM/PMC.
19. Collaborates and participates in all regional CRNs hospitals routes task forces to perform close cases on daily basis.
20. Ensure, performs and follows the quality of services according to CMS, NCQA regulations and corporate processes and policies.
21. Responsible on business day hours connected and attend regional conference calls with CRN Supervisor and Regional AIMDs by planned phone calls, following the department established processes according on daily basis.
22. Participates on applications upgrades, testing and/or new tools implementations.
23. Performs additional job-related duties or special task as assigned by appointed CRNs Supervisor or Manager.
24. CRN will be updating the primary and secondary Diagnosis to developed reports for the Model of Care to assure the adequacy to ensure quality report.
25. Determinates necessity of services for Authorizations of Planned and Unplanned Transitions of Alternate Level of Care from acute admission and/or sub-acute Hospitals Discharges, including the outpatient admissions requests to Skill Nursing Facilities and/or Rehabilitation Centers.
EDUCATION AND EXPERIENCE
- Bachelor’s Degree in Science of Nursing.
- Current R.N. permanent license in Puerto Rico and Collegiate.
- Five years clinical acute care hospital experience; ICU, Emergency Medicine Department, Medical / Surgical Department.
- One to three years experience in utilization management or health services setting preferred.
GENERAL SKILLS AND REQUIREMENTS
- Must possess a current Puerto Rico driver’s license and is able to commute to various facilities on any given day from the office work site.
- Must have ability to work as a team player with excellent verbal and written communication skills.
- Strong interpersonal skills.
- Independent and a self – starter.
- Ability to analyze and solve problems.
- Familiarity with State Federal Governmental regulations and national accrediting agency requirement preferred (CMS/NCQA or regulatory agencies).
- Availability to work flexible schedules including weekends and holidays.
- Computer literate in Microsoft Windows applications, software and Internet.
- Performs tasks requiring independent knowledge judgment in addition to instructions and procedures provided.
- Must be able to function with frequent interruptions, accept change and be able to prioritize tasks efficiently when faced with competing demands.
LANGUAGE SKILLS
- Ability to speak, read and write in English and Spanish, preferable Bilingual in English to Spanish.
- Ability to read, analyze, and interpret general business periodicals, operating and maintenance instructions, procedure manuals, professional journals, technical procedures, or governmental regulations.
- Ability to write reports, business correspondence, and procedure manuals.
- Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
MATHEMATICAL SKILLS
- Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume.
- Ability to apply concepts of basic algebra and geometry.
- Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
REASONING ABILITY
- Ability to define problems collects data, establish facts, and draw valid conclusions.
- Ability to interpret an extensive variety of technical instructions in mathematical or diagram
INTERPERSONAL RELATIONS
Internal Contacts
Staff employees
Management at all levels of the organization
Staff employees
Management at all levels of the organization
External Contacts
External Providers
External Clients
Government and Federal Agencies
External Providers
External Clients
Government and Federal Agencies
PHYSICAL AND MENTAL DEMANDS
- Must be able to sit and stand for long periods of time with enough mobility to perform all job duties in the hospital an office environment.
- While working the employee is standing, sitting, walking, talking, and listening most of the time.
- The job also requires reaching objects with hands; stooping and bending to file and maintain orderliness; mobility to complete errands.
- This job also requires lifting objects up to 10 pounds.
ENVIRONMENTAL AND WORKING CONDITIONS
- Normal busy office environment.
- Moderate noise (examples: business office with computers and printers, light traffic).
- Travel required general exposure to weather conditions while traveling and different traffic situations.
This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.
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