Job Number 61629
Posted 3/28/2019
Account Northern Light Mercy Hospital
Department CARE MANAGEMENT (Utilization Review)
Location |ME| MERCY STATE STREET, ME 04101
Schedule Pool/Per Diem
Shift Day
Hours 8
Job Details Job Summary:

The Care Manager/RN as part of a multidisciplinary team, including physicians, and payors, ensures the patient's progress in the acute episode of care through post discharge and is quality driven while being efficient and cost effective. The RN Care Manager and MSW Care Manager work collaboratively to ensure patient needs are met and care delivery is coordinated across the continuum. The RN Care Manager seeks the expertise of the MSW Care Manager to resolve psychosocial patient care issues and to develop complex patient transition/discharge plan as needed. The incumbent interacts with patients, family members, healthcare professionals, community and state agencies in this effort. The Care Manager/RN serves as a liaison between the hospital and community agencies or facilities for the exchange of clinical and referral information. The Care Manager/RN is responsible for maintaining hospital compliance with the Quality Improvement Organization (QIO) series and CMS guidelines. In addition, the Care Manager/RN provides case review information to third party payers and assists in the denial and appeals process as well as assessing quality, levels of care and identifying and reporting potential risk management issues. The incumbent performs duties and tasks in accordance with performance standards established for the job. The incumbent may have access to highly confidential patient, employee and/or Mercy proprietary information, and must handle & protect the information in accordance with hospital & system policies, HIPAA requirements and the highest level of ethical standards. The incumbent is responsible for reporting all security events, potential events, or other security risks to the organization. The incumbent is responsible for participation in and completion of all patient safety initiatives appropriate to the position. In addition, the incumbent conducts all job responsibilities according to the Mission and Values of Mercy Hospital.


Position requires licensure by the State of Maine as a Registered Nurse (RN). Appropriate clinical certification is also preferred. A four-year degree with a Baccalaureate in Nursing from a program accredited by the National League for Nursing is preferred. A minimum of four (4) years of clinical experience as a Registered Nurse in an acute care setting is preferred. Experience in dealing with extended care facilities and community healthcare agencies is desired. A working knowledge of insurance coverage, various governmental programs, available community care agencies and long-term care facilities is preferred. Excellent interpersonal skills are required as the incumbent interacts with patients, families, physicians, and other caregivers through out the continuum. Must have excellent analytical and problem solving skills to assess patient discharge needs and evaluate applicability of available resources. Must have the judgment and initiative to operate independently and autonomously in the assessment, development, and implementation and follow up of discharge plans with minimal guidance from the department manager. Must be highly accountable for timely and accurate planning and preparation to assure safe discharges and cost effective utilization of available resources for the continuation of patient care.

Principal Responsibilities:

1. Works in conjunction with physicians, nurses, Care Management Team and others to assess, plan and initiate patient plan of care.

· Reviews patient charts daily or as needed.

· Utilizes MSW Care Manager for appropriate referrals: patient/families with complex psychosocial, on-going medical discharge planning issues, continuing care needs and end of life issues.

· Attends focus of care rounds per unit policy.

· Communicates targets and identified standards of care through collaboration with multidisciplinary team to reduce LOS and resource consumption.

· Collaborates with patients, families and other members of the interdisciplinary team as needed.

· Insures that all critical elements of the care and discharge plan have been communicated to multi-disciplinary team, patient and family including expediting teaching needs.

2. Facilitates and coordinates details of actual discharge to appropriate agencies.

· Initiates discharge plan within 24 hours of admission

· Provides and updates referrals to facilities through online/software discharge planning tools.

· Reviews and completes all appropriate information accompanying patient facility.

· Acts as a liaison between hospital and post acute facilities to facilitate returns/admissions.

· Facilitates arrangements for time and mode of transportation to facilities for patients.

3. Facilitates and coordinates individualized discharge plan.

· Arranges and participates in care conferences with unit staff, home care staff, patients and/or families.

· Provides adequate avenues of communication through on-going documentation in Cerner, eDischarge and telephone/verbal reporting or electronic tools.

· Coordinates and communicates with home care agencies regarding expected standards of care for requested specific treatments.

· Identifies and provides information on requested procedure or medicines.

4. Serves as a resource to physician and hospital personnel regarding available agency, facility, and community services to assist in discharge planning.

· Discusses specific continuing care needs with physicians and hospital personnel on a regular basis.

· Collaborates with other Care Management team members as needed.

5. Completes appropriate State of Maine forms.

· Monitors the completion of the MED for all first time Mainecare transfers to nursing facilities.

· Alerts contracted agency to complete The MED on Mainecare patients with expired bed holds.

· Alerts contracted agency to complete The MED on Mainecare patients with need for community programs.

6. Ensures adherence to Quality Standards and Participation in Quality Monitoring and Improvement

· Participates in departmental and hospital Quality Improvement programs by documenting the required indicators in Midas for focused review.

· Documents disposition of patient at discharge.

· Provides adequate documentation of initial assessments, on going of progress notes in Cerner and reviewing of all referrals for accuracy and content prior to discharge.

· Accepts responsibility for further development of professional learning and growth.

· Actively participates in interdisciplinary projects using the Quality Improvement plan.

7. Medical Record Review:

· Conducts inpatient admission reviews for appropriateness of setting.

· Conducts on-going case review for continued stay criteria and enters data.

· Monitors quality of care using predetermined criteria.

· Reports potential risk management issues as through medical record review.

· Enters data as requested to support Quality Improvement initiatives in Midas.

8. Third party payer Reporting:

· Using approved criteria conducts admission and continued stay review to ensure appropriateness of the setting and timely implementation of the plan of care, to monitor the patient's progress along the continuum of care and intervenes as necessary to ensure appropriateness of setting and that the services provided are quality, efficient and cost effective

· Consults with Physician Advisor and leadership as necessary to resolve barriers through appropriate administrative and medical channels.

· Responds to requested telephonic insurance reviews involving admissions, continued stay, and discharge planning as well as contact for onsite reviewers.

· Documents in appropriate electronic system by the close of business each day.

· Communicates with admitting and pre-certification regarding level of care status.

9. Computer Skills:

· Demonstrates competency in accessing and documentation in approved programs, which currently include Midas, Cerner, eDischarge and email system.

10. Professional Development:

· Assumes responsibility for own professional growth and attendance to in-service educational opportunities.

· Seeks opportunities to meet learning needs through workshops and literature.

· Maintains knowledge of necessary QIO transmittal services to facilitate appropriate level of care and denial activities within the hospital.

11. Performs additional duties as required or assigned.

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.

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