Care Coordinator (Utilization Review Registered Nurse)
- Location: Denison, IA
- Posted: Mar 5, 2019
Plans, organizes and controls resources in a cost effective manner while preserving quality patient care and services. Identifies, assesses, and plans for the discharge needs of patients following discharge from the hospital. Works closely with physicians and payer to assure proper use of fiscal and medical resources. Assess needs for care coordination in Outpatient and Ancillary Departments.
Essential Duties and Responsibilities:
- Interview patient and family members to obtain information about home environment, family relationships, health history, and patients personality traits.
- Assist patients and family to understand, accept, and follow medical recommendations.
- Perform a variety of services such as arranging for discharge, placement of patients into foster or nursing homes and alleviation of anxieties and fears.
- Utilize resources to assist patient to resume life in the community or to learn to live with a disability.
- Collaborates with patients, families, medical and hospital staff in order to formulate plans of care.
- Services as a liaison between hospital and community resources.
- Assures all Medicare/Medicaid admissions meet admission criteria of specific program.
- Completes follow up on all admissions that do not meet criteria, or may be a discharge problem.
- Issues non-coverage notices to Medicare/Medicaid patients when necessary.
- Completes initial clinical review and continued stay review. Reports pertinent clinical information to approved third-party payers. Assists with meeting guidelines for managed care programs.
- Assures that referrals are complete for reimbursement.
- Communicates with community agencies to provide medical information as needed to facilitate discharge and continuity of care.
- Works with nursing to identify, document and provide appropriate follow-up for place of care variations for all patients.
- Documents and records progress accurately on medical record.
- Conducts medical care evaluation studies as directed by Utilization Management, i.e., patient admissions, duration of patient hospitalization, ancillary and professional services, etc.
- Collaborates on development and broader implementation of critical pathways for target populations through medical record review, analysis of physician orders, discharge criteria and other data as appropriate.
- Assists with the collection and maintenance of records as needed by department, governmental oversight organizations (OSHA, DHS, etc.) and as required by law.
- Provides input for the development of the annual department budget.
- Reports denials and other problems to the attending physician and starts the initial appeal process as determined by the payer.
- Documented on reviews, outcomes, denials and the appeal process.
- Serve on committees and attend meetings as requested by supervisor.
- Assess needs for care coordination in Outpatient and Ancillary Departments.
- Complete QAPI activates for discharge planning, utilization and swing bed.
- Participates in and attends Utilization Review and Revenue Cycle meetings as directed by supervisor.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.