RN Access Specialist Case Manager - Wichita Falls, TX - Utilization Review
Company: United Regional Health Care System
Location: Wichita Falls
Posted on: August 5, 2022
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Job Description:
RN Access Specialist Case Manager - Wichita Falls, TX
Summary of Essential Functions
Conducts medical record review for medical necessity and level of
care for patients accessing hospital care by way of an Emergency
Department visit, a transfer from another facility, or a direct
admission.-- Uses nationally recognized acute care indicators and
criteria as approved by medical staff, The Joint Commission, CMS,
and state agencies to include admission orders and admission
status.
Screens for appropriateness of inpatient status or observation
services and level of care following review of relevant medical
documentation, medical guidelines, and insurance benefits and
requirements. --Documents reviews and actions taken to support
hospital reimbursement and utilization management activities and to
facilitate tracking and trending of data.
Concurrently screens outpatients and patients in observation for
appropriateness of hospital stays.-- Monitors patients in the
Clinical Decision Unit for progression of care and timeliness of
services.-- Communicates and coordinates with physician, CDU, and
Case Management staff.
Assists in performing timely retrospective medical record reviews
(for patients undergoing procedures to determine) appropriateness
of immediate postoperative bed status orders based on actual
procedures performed.--
Serves as a resource to ED and admitting physicians, house
supervisors, and other nursing staff.-- Provides education and
information on resource utilization and use of screening criteria.
Works closely and compatibly with ED and admitting physicians,
nursing staff, Utilization Review Specialists, Case Managers,
Social Workers, and hospital support staff.
Assists all disciplines of care with management of cost of care
with benefits of patient safety, clinical quality, patient
satisfaction to ensure optimal outcomes.
Will arrange and ensure all elements of the transitional care plan
are implemented and communicated to key stakeholders including but
not limited to hospital care team, patient/ family/caregiver,
payors and post-acute care providers.
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Educational and Certification Requirements
Graduate of a professional school of nursing with a Bachelor of
Science (preferred) or Associate Degree in Nursing
Current certification in Basic Life Support (BLS) (preferred)
Current CPI training (preferred)
ACM and/or CCM certification preferred.
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Qualifications and Licenses
Registered Nurse with current Texas license
In good standing with governing board in Texas
Knowledge/Skills/Abilities
Minimum two years recent acute care hospital experience
Propensity for compassion and ability to related to patients and
families with various needs
Expert knowledge of InterQual Level of Care Criteria or MCG,
Knowledge of local and national coverage determinations and coding
and healthcare reimbursement
Basic computer knowledge including navigational skills and word
processing
Excellent and Effective written and verbal communication skills and
ability to interact all care team members, patients/families, and
post-acute care providers and services.
Sound judgment and decision-making skills, ability to prioritize
daily workload, pay attention to details
Ability to demonstrate proficiency in-- use and application of all
electronic tools
Ability to build positive relationships, effect change, and perform
critical analysis
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Physical Requirements
Requires prolonged standing and sitting, along with frequent
bending, stooping and stretching
May require lifting up to 25 pounds
Requires eye-hand coordination and manual dexterity
Requires the ability to distinguish letters and symbols, along with
normal vision range
Duties and Responsibilities
Assess patients physical health, mental health, social wellness,
needs , preferences and abilities formulate care plan and /or
alternate care plans as deemed appropriate
Review medical records of direct admit and transfer patient
requests prior to patient's arrival to ensure compliance with CMS
guidelines regarding appropriateness of level of care.-- Promote
use of evidence-based protocols and/or order sets to influence high
quality and cost effective care.--
Follow established guidelines to determine appropriateness for
inpatient level of care or observation services for patients
admitted through the ED, direct admission, or transfer from another
facility.-- Document reviews within established time frames using
current screening tools designated.-- Use appropriate criteria
subsets based on patient condition and medical documentation.--
Promote medical documentation that accurately reflects intensity of
services, quality and safety indicators, medical decision making,
and a treatment plan that describes the patient's medical necessity
for an acute hospital stay.
Conduct concurrent reviews for outpatient and observation patients
in-house. Take timely and appropriate actions for patients
identified as meeting medical necessity for acute hospital
inpatient status.-- Strive to prevent loss of hospital revenue from
lost inpatient days.--
Communicate and coordinate with Utilization Review Specialists for
completion of duties handed off after hours or when handing cases
to them at the start of their normal work hours when needed for
difficult or complex cases to facilitate continuity of review
processes.--
Review patient medical records for postoperative patients on the
day of surgery when handed off by a Utilization Review
Specialist.-- Determine appropriateness of postoperative bed status
orders based on actual procedures performed.-- Identify unplanned
or incidental inpatient-only procedures and take timely actions to
obtain inpatient orders as needed.-- Follow guidelines to close
cases for outpatients discharged post procedure.
Understand compliance issues and CMS Conditions of Participation by
referring appropriate cases for secondary review.-- Follow
established guidelines for completion of the referral process and
documentation of determinations made after regular duty hours.--
Follow Condition Code 44 guidelines as applicable.-- ----
Work closely with decision support personnel to review resource
utilization data and trends to identify outliers who may benefit
from real time coaching to improve outcomes.-- Participate in
facility in-service activities that promote greater understanding
of the case management process and access utilization review
functions.
Proactively consult with physicians, nurses, ED social workers,
Utilization Review Specialists, and other hospital staff on
compliance issues and appropriate resource utilization.
Maintain a positive, professional, and collegial demeanor that
fosters teamwork and cooperation.-- Adhere to the Standards of
Behavior established by United Regional.-- Preserve the basic human
rights of expression, decision, action, and personal dignity for
all patients and families.-- Respect the cultural diversity of all
patients, families and employees of United Regional.
Attend meetings and perform all other tasks and responsibilities as
necessary.
Keywords: United Regional Health Care System, Wichita Falls , RN Access Specialist Case Manager - Wichita Falls, TX - Utilization Review, Executive , Wichita Falls, Texas
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