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RN Access Specialist Case Manager - Wichita Falls, TX - Utilization Review

Company: United Regional Health Care System
Location: Wichita Falls
Posted on: August 5, 2022

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.

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.

Qualifications and Licenses

Registered Nurse with current Texas license
In good standing with governing board in Texas


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

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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