Job details: Monday-Friday, possibly some weekends

The RN Case Management/Utilization Review is responsible for following Adena's Case Management/Utilization Program that integrates the functions of utilization review, discharge planning, and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated resources. Adena's case management model outlines a collaborative practice to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimal outcomes.

This role is a dual role for Case Management and Utilization review.

The RN Case Management/Utilization Review is responsible for following Adena's Case Management/Utilization Program that integrates the functions of utilization review, discharge planning, and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated resources. Adena's case management model outlines a collaborative practice to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimal outcomes.

Job Duties & Responsibilities:

• Promote Adena's mission, vision, values, and guiding principle
• Facilitate team meetings that foster interdepartmental collaboration with the patient and their family as deemed necessary, this includes multidisciplinary meetings and Utilization Review/Case Management meetings. Provides in put in such meetings regarding utilization management and discharge planning.
• Responsible for evaluating and screening potential admissions to the facility where appropriate.
• Communicate daily with admissions personnel regarding admission and discharges to various units.
• Initiate ongoing communication with the patient and patient's family to assess discharge needs.
• Communicate with physicians to ascertain their plans for a timely discharge.
• Document discharge planning as an ongoing review
• Knowledgeable about the patient's financial status, diagnosis and discharge needs.
• Responsible for home care needs being met by the time of discharge, with a goal of arrangement completed 24 hours prior to discharge when date of discharge is known
• Cooperate with insurance companies, based on information received.
• Manage and collaborate with the healthcare team on Swing Bed or Skilled Nursing Facility placement and complete required documentation as necessary.
• Ensure that quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting the data to the appropriate department; reports and identifies data that indicates potential areas for improvement of care and services provided within the system.
• Assist as needed with obtaining referrals, prior authorization for Home Health Care, DME, SNF, acute rehab and appointments.
• Educates physicians and staff on appropriate level of care/utilization issues.
• Manages the appropriateness of admission, intensity of service, length of stay throughout the hospital stay and certification for assigned patient population within established guidelines.
• Manages denials and appeals of service for assigned patient population in collaboration with the clinical denials team.
• Participates in multi-disciplinary rounds with the healthcare team for assigned patient populations. Concurrently reviews patients records for continued medical necessity of hospitalization, level of care, efficient utilization of ancillary and support services, quality issues, delays in services, and potential discharge planning problems; facilitates appropriate interventions as needed.
• In collaboration with the healthcare team, develops a comprehensive discharge plan for assigned hospitalized patients and families, consulting with Social Worker as needed for complex discharges, included but not limited to readmissions and high risk populations. Understands medical care regimen and interacts actively with the patient/family, physicians and health care team to review discharge plans and to ensure discharge orders are obtained
• Facilitates transition planning across the continuum by involving the patient, family, physician and healthcare team members for assigned patient populations. Works with patients and families to promote self-management support of chronic diseases through individualized plans with short term and long term goals.
• Reviews clinical needs and condition of all hospitalized patients using evidenced based guidelines to assist in determining medical necessity and level of care in accordance with Adena Utilization Management Plan.
• Refers patients and families to appropriate post-acute services and community resources in coordination with the Care Management team, including assigned Social Workers and Care Management Assistants, in accordance with state and federal regulations
• Concurrently assess and review Readmissions and High Risk Patients to promote appropriate and efficient care. Facilitate referrals to post-acute management (PCMH, Payer Navigation, etc.)
• Functions as a resource for estimated length of stay, clinical support of coding, resource utilization, intensity of service, clinical care processes, third party payor guidelines, and review criteria.
• Other duties as assigned

Education Requirements:

• Bachelor's Degree (Nursing)
• RN - Registered Nurse with Current Ohio License
  Case Management Certification from the Commission for Case Manager Certificaiton within 3 years of hire