Summary

Continuously evaluates the quality, care, treatment and outcomes of complex patient populations. Collaborates with the patient/family and caregivers to facilitate necessary resources and options for post-discharge services to support a safe discharge. Provides consultation with physicians and other members of the interdisciplinary healthcare team to facilitate patient progression to discharge. Ensures clinical documentation supports medical necessity criteria and meets regulatory requirements. Communicates the clinical status of patients related to medical necessity criteria to the physician advisor (internal or external) and/or the Inpatient Care Transitions leadership team as needed. Monitors length of stay and documents avoidable days for delay of discharge. Reviews payer source for potential negative financial liabilities to the patient.

Education

Bachelor of Science in Nursing (BSN) required.

Licensure/Certification

Valid Indiana Registered Nurse license required. Certification in Case Management highly desirable.

Experience

Required at least 2 years of experience in acute care setting. Preferred experience in Case Management activities. Preferred experience or knowledge of InterQual criteria.

Other Qualifications

Demonstrates knowledge of DRGs managed care initiatives, payment methods, and statistical analysis. Demonstrates competency at completion of InterQual training program and ongoing Inter-reliability testing. Demonstrates understanding of managed care concepts. Demonstrates ability to engage in complex clinical decision-making. Demonstrates a strong commitment to interdisciplinary collaboration and communication. Demonstrates critical thinking and analysis and conflict resolution skills. Must have good verbal and written communication skills. Must have excellent people skills and the ability to problem solve efficiently and effectively. Must be available to work flexible hours, including weekends and other times when deemed necessary.