RN Utilization Review Coordinator-Emergency Department

Company: Saint Joseph Mercy Health System
Location: Pontiac
Posted on: June 20, 2022

Job Description:

Employment TypeFull timeJob DescriptionFacilitates the coordination of patient care, through comprehensive clinical assessment, planning, implementation and overall evaluation of individual patient needs utilizing assessment skills, clinical expertise, and specific knowledge of criteria and third party payor information. Enhances the quality of patient management and satisfaction, to promote continuity of care and cost effectiveness through the integration and functions of case management, utilization review and discharge planning. Manages efficient and effective movement, including discharge of the patient receiving care in either the Emergency Room or Emergency Transition Unit.Position Qualifications: Minimum Education, Licensure / Certification and Experience Required. A. Education --- Bachelor of Science degree in Nursing preferred. --- Graduate of an accredited school of nursing. B. Licensure / Certification --- Current licensure to practice in Nursing in the State of Michigan. --- Case Management certification required or progression toward a completed certification within two years of transfer or hire. Minimum Education, Licensure / Certification and Experience Required. C Special Skill / Aptitudes --- Excellent interpersonal skills with the ability to interact with the healthcare team, peers, patients, families & community to facilitate problem resolution. --- Possesses excellent clinical assessment and analytical skills necessary to identify medical and discharge needs of patients and families. --- Proficient in various case management related software programs. Ability to utilize SJMO programs including but not limited to EPIC, Midas, Allscripts, Pathways is preferred. --- Demonstrated team work, initiative, and an openness to learning new things. Ability to adapt to rapidly changing regulatory requirements. --- Knowledgeable of the functional operations of utilization review, discharge planning, clinical assessment and third party payors preferred. --- Ability to work in a demanding and stressful environment, where prioritizing is essential while maintaining a professional demeanor in difficult situations. --- Ability to work autonomously at times and accountable for own actions and outcomes. --- Excellent customer service orientation skills necessary in order to deal effectively with various levels of hospital personnel, outside customers and community groups. D. Experience --- Five years of clinical experience in nursing (medical surgical, critical care and/or emergency room) with recent (within 2 -3 years) experience in utilization review/management/discharge planning or case management preferred. --- Current knowledge of third party payor requirements and applied clinical admission/discharge criteria (Interqual and MCG) preferred. --- Knowledge of federal, state and local regulation affecting utilization review programs and payments. --- Knowledge of regulatory and accrediting agency standards and regulations relative to utilization review.Duties / Responsibilities: 1 Utilizes clinical judgement and admission criteria and uses it to collaborate with the ED Attending Physician, to assess patients for severity of illness and intensity of service in order to make recommendations regarding the most appropriate level/site of care. 2 Verifies third party payor requirements for potential admissions and acts as a liaison between the patient, physician and the payor, by communicating pertinent clinical information in order for admission authorization to be obtained. 3 Collaborates with the health care team, third party payors, and patients/families to resolve patient care issues that may impact Length of Stay (LOS), cost, patient safety and/or quality. 4 Obtain third party payor authorizations as indicated for those who require calls both for service and continued stay (Emergency Room Inpatients-ERIH, extended stay ER patients). 5 Uses clinical judgement and established criteria and guidelines in identifying infection control, risk management, documentation and utilization issues and escalates these issues to enhance positive outcomes. 6 Assists the Emergency Room Physician and/or Attending Physician in identifying patient care needs that may not require hospitalization but could be more appropriately provided in an alternate care setting and works to coordinate those needs on behalf of the patient. 7 Actively participates in core Indicator management, documentation and process improvement activities when appropriate. 8 Works with the Logistic Center staff to place patients in the right bed the first time according to patient placement guidelines, ensuring accurate documentation of the patients status is clearly reflected in the Electronic Medical Record (EMR). 9 Collaborates with patients/families and health care team members ,to identify coordinate and facilitate the appropriate resources needed for post hospital care. 10 Takes ownership for self education and actively participates in Department meetings, hospital and system wide committees, quality and process improvement projects as requested. 11 Utilizes EHR (Executive Health Resources) to refer all patients not requiring pre-certification that are not meeting inpatient criteria for appropriateness of admission vs. observation and records the outcomes in the MIDAS+ HCM module. 12 Accurately documents a complete clinical assessment (face to face), including interventions and goals for patients in accordance with documentation standards, policies, procedures and/or guidelines in the electronic medical record (EMR). Ensures variances and delays in care are documented and escalated to the Physician Advisor. 13 Participates in multidisciplinary patient care rounds/care conferences to review treatment goals, optimize resource utilization, provide patient/family education on specific post hospital care needs.

Keywords: Saint Joseph Mercy Health System, Pontiac , RN Utilization Review Coordinator-Emergency Department, Healthcare , Pontiac, Michigan