GENERAL SUMMARY:

The Care Transitions RN or SW conducts day-to-day activities for the clinical, psychosocial and utilization coordination of the patient’s hospital experience. Proactively consults with the interdisciplinary team which includes but is not limited to hospital patient care staff, physicians, patient support and family and community resources to assure a smooth transition for the patient through appropriate levels of care in order to facilitate quality outcomes.

PRINCIPAL JOB FUNCTIONS:

*Commits to the mission, vision, beliefs and consistently demonstrates our core values.

*Utilizes clinical skills to create and update personalized transitional care plans for patients.

*Performs transition planning activities at onset and throughout the patient’s hospitalization.

*Collaborates with the patient’s provider and other healthcare team members in managing the patient’s length of stay and determining the appropriate level of care for transition planning.

*Assists in identifying need for supportive counseling or post discharge extended psychosocial therapy and consults with attending Physician for referral to appropriate provider.

*Maintains awareness of financial reimbursement methodology, utilization management, payer/reimbursement practices and regulations and participates in resource stewardship.

*Promotes quality improvement initiatives and health care outcomes based on currently accepted clinical practice guidelines and total quality improvement initiatives.

EDUCATION AND EXPERIENCE:

Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Minimum of two (2) years recent clinical experience required. Prior care coordination and/or utilization management experience preferred. Basic Life Support (CPR) certification required.

OR

Masters degree in Social Work (MSW) from a School of Social Work OR Masters degree in Counseling or related field required. Current certification as a Licensed Mental Health Practitioner (LMHP) by the State of Nebraska preferred. Prior case management experience desired.

ACUTE REHABILITATION

ADDITIONAL JOB FUNCTIONS:

In addition to the principal job functions contained on the primary job descriptions, the following duties are also required in the department noted above.

1. Responsible for the early identification of potential patients through interdisciplinary team members and medical record review.
2. Provides education to patients, family and support members, internal and external referral sources on Rehab program benefits and services; coordinates tours of facility when requested.
3. Performs utilization review activities, including preadmission screening, insurance verification for benefits, medical necessity reviews, denial and appeals and coordinates admissions with admitting physicians and staff.
4. Serves as an internal and external resource regarding Medicare/Medicaid rules, regulations and policies; 3rd party and managed care contracts, and authorization for post-acute services.

EMERGENCY DEPARTMENT

ADDITIONAL JOB FUNCTIONS:

In addition to the principal job functions contained on the primary job descriptions, the following duties are also required in the department noted above.

1. Collaborates with the ED physicians, admitting physicians, and Bed Management to assist in determining appropriate bed status/classification for all patients.
2. Completes medical necessity reviews utilizing approved evidence based guidelines/criteria for patients being admitted to the hospital from all portals of entry, including but not limited to: ED admissions, direct admissions, hospital to hospital transfers, post procedure admissions, and surgical admissions.
3. Completes high risk screening for discharge planning and coordinates with social work and healthcare partners for potential post-acute needs.
4. Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay.

UTILIZATION MANAGEMENT

ADDITIONAL JOB FUNCTIONS:

In addition to the principal job functions contained on the primary job descriptions, the following duties are also required in the department noted above.

1. Performs utilization review activities, including concurrent and retrospective reviews as required.
2. Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria.
3. Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm.
4. Participates in concurrent and retrospective denials and appeals process by researching issues surrounding the denial, participating in all levels of the appeal and process follow-up.
5. Serves as an internal and external resource regarding appropriate level of care; admission status/classification; Medicare/Medicaid rules, regulations, and policies; 3rd party and managed care contracts; discharge planning; and length of stay.