Nurse Case Manager - Utilization Review

Description: The Nurse Case Manager - Inpatient is responsible for coordinating the care and service of assigned patients with physicians, nurses, social workers and other members of the healthcare team to facilitate the progression of care from hospital admission through discharge. The Nurse Case Manager- Inpatient is also responsible for ensuring that the patient is placed in the appropriate level of care while monitoring the utilization of healthcare resources and discharge planning to achieve the desired clinical, financial, and resource utilization outcomes. Typical Duties: Provides an assessment for all observation status patients prior to observation placement. The patient is to be assessed throughout the shift to determine discharge readiness or the need to convert to an inpatient status by using the approved medical appropriateness criteria and all third-party payer regulatory requirement. Performs initial status review and level of care placement on all patients in an inpatient status using approved medical appropriate criteria in addition to third-party payer regulatory requirements. Conducts an initial clinical assessment on assigned patients as well as discharge planning assessment prior to admission, at the time of admission, or at discharge. Meets directly with the patient, family, and/or representative to assess needs and develop an individualized discharge plan based on the patient’s medical diagnosis, treatment plan, financial resources, and psychosocial issues, etc. Reassesses the discharge plan throughout the patient’s hospitalization with input from the healthcare team and patient, family, and/or representative and modifying as needed. Collaborates with the multi-disciplinary care team to ensure all needed clinical information is provided to the appropriate entities for the assigned level of care and supports the concurrent appeal process for any reduction in level of care or denial as requested. Maintains active communication with the patient, family, and/or representative, physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management; documents each component of the case management process and related activities. Identifies appropriate services not related to admission and assists in arrangement of services on an outpatient basis. Leads the Unit’s daily interdisciplinary rounds to ensure a comprehensive plan of care is developed, including identification of patient needs, assignment of tasks to resolve clinical issues, review of discharge barriers, and identification of discharge planning options. Generates referrals to the Case Management Physician Advisor according to departmental policies. Serves as an educational resource for physician, nursing staff and others concerning case management strategies essential in meeting the organization’s quality, utilization, financial and customer satisfaction objectives. Performs other related job duties as assigned.