CM/UR RN at Speare Memorial Hospital – Plymouth, New Hampshire

Case Manager/Utilization Reviewer General Summary: Reporting to the Director of Patient Care Management, this position will perform the following functions: Generally: • Comply with hospital and departmental policies, procedures, regulations and standards as related to job. • Demonstrate hospital’s stated mission and values of teamwork, respect and communication with co-workers, patients, families and visitors. • Actively and appropriately participate in problem-solving identification and resolution, both intra- and inter-departmentally. • Meet department customer service standards and strive to enhance the level of customer service provided. Case Management: in collaboration with physicians, nurses, and other health care professionals assess, plan, coordinate and oversee the plan of care for the in-patient population, and effectively prepare patients for discharge through patient/family meetings and coordination of home services. Also work with Emergency Department staff, when requested, regarding clarification of admission criteria. Utilization Review: ensure appropriate use of hospital resources to support quality care safely, timely, effectively, efficiently, equitably, and with a focus of patient centeredness. Essential Job Functions: Case Management: • Coordinates the in-patient’s plan of care in collaboration with physicians, nurses, and other members of the health care team. • Coordinates the multidisciplinary discharge planning meetings for in-patients to evaluate and identify potential and actual discharge planning needs. • Coordinates appropriate referrals and arrangements for discharge. • Provides support as needed to the Emergency Department for admission guidance and community resources. • Documents pertinent information and status of discharge arrangements in the medical record. Utilization Review: - • Reviews hospital resources for utilization and appropriateness, with monitoring for severity of illness and intensity of service in defining appropriate level of care, potential alternatives to acute setting and efficiency with which services are rendered. Monitors of length of stay in conjunction with screening criteria, length of stay guidelines, patient status and physicians discharge criteria. • Communicates with payers, notifying of admissions, and provision of medical information to determine level of care and/or continued stay approval. • Monitors compliance with CMS regulations. • Provides referrals to the Chief Medical Officer (Utilization Review MD) for peer review of those admissions and continued stays for which the medical necessity for services and appropriateness of the level of care are questionable, according to the screening criteria and guidelines, and those for which a determination cannot be made due to insufficient documentation by the attending physician. • Monitors payer denials, appropriate and timely responses, and corrective action plans including communicating with the Business Office about denial issues. • Communicates with the admissions department in fulfilling payer requirements for admission precertification and notification. Qualifications: Education Required: Graduate of an accredited School of Nursing Preferred: Bachelors of Nursing or higher Work Experience Required: Minimum of two years previous nursing experience in acute care setting. Preferred: 1. In-patient critical care experience 2. Experience communicating with third party payers Licensure/Certifications/Registrations R Required: 1. Registered Nurse with valid NH state license 2. BLS certification Preferred: 1. Certified in a relevant specialty. Other Skills/Knowledge Required: - 3 - 1. Excellent assessment, problem-solving, communication, interpersonal, and documentation skills. Flexibility. Preferred: Working Conditions/Physical Demands: • OSHA Blood borne Pathogen Category: 2 Physical Demands 1. Strength (lift, carry, push, pull) Maximum Lift Frequent Lift/Carr