Provides leadership in the coordination of patient-centered care across the continuum, develops a safe discharge plan through collaboration with patients / caregivers and multidisciplinary healthcare team
Facilitates appropriate LOS, patient experience, and reimbursement for all patientsRoles and Responsibilities:
Assumes roles in assessment physical, psychosocial, & economic needs for transition of care planning to a variety of levels of care; delegates to others as appropriate
Facilitates the development and communication of the care plan to appropriate internal / external providers (e.g. primary care, specialty care, etc.)
Coordinates and expedites final transfer and discharge with staff, patient, family and facility
Reviews daily treatment plan with physicians, nurses and patient / families and other pertinent stakeholders to insure interdisciplinary communication and coordination is occurring
Presents alternatives to inpatient stay to attending MD, team and patient / family based on assessed patient level of care and insurance benefits
Documents, verifies, and validates specific data required to monitor and evaluate interventions and outcomes
Interviews and collects patient data and chart reviews related to readmission and appropriately notifies care team
In collaboration with Utilization Management (UM), obtains or ensures acquisition of appropriate pre-certifications authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelines
In collaboration with Utilization Management (UM), obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements
Documents, monitors, intervenes/resolves, and reports clinical denials/appeals and supports retrospective payer audit denials; collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physician advisor, and third party payers, etc.
Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc., and serves as an educational resource to all Health System staff regarding utilization review
Seeks consultation from Care Management leadership with plans for potential or actual resource intensive patients
Communicates via telephone and electronically with outpatient providers in an effort to enhance the continuum of careEducation and Experience Requirements:
- Associates degree in nursing required; must be enrolled in BSN program within one (1) year of hire and completion of BSN within 3 years of hire.
- Active Maine RN license or eligibility to obtain required.
- At least two years ofrecent clinical acute care nursing experience; preferred experience in care facilitation and management and utilization review.
- Active BLS certification. required.- ACM, CCM or other certification applicable to utilization management within 3 years of hire required.Skills and Attributes:
Strong communication skills
Ability to develop and maintain positive relationships with customers internal and external to Health System Enterprise
Care coordination / discharge and transition planning and community resource knowledge preferred
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.