Hospital Nurse Care Coordinator/Utilization Management Specialist - Welia Health

SUMMARY

Responsible for providing care coordination to patients during their acute stay and the transition from acute care to the next level of care. This individual will be the leader in coordinating with the interdisciplinary team to develop a safe discharge plan for the patient, including involving the patient and family in health education.

Coordination of care begins with the patient at diagnosis and remains throughout the entire chronic disease journey including diagnosis, treatment, maintenance of quality of life, survivorship and/or end of life. This person is the expert in acute illnesses, community education on optimizing health, disease prevention and education

Assists in coordinating and communicating patient needs to the multidisciplinary care team. Concurrently reviews and assists in determining appropriate patient admission status, level of care, and discharge planning. Resource for discharge appeals, denials, insurance communication and regulations. Responsible for utilization management plan.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

Utilizes clinical and applied knowledge of utilization principles to evaluate pre-admission, hospitalization, and discharge criteria.

Analyzes patient records to determine legitimacy of admission, treatment, and length of stay in health care facility to comply with government and insurance company reimbursement policies. Documents as appropriate in organization documentation system.

Round at the bedside with provider on all inpatients daily, with prioritization being patients who may be discharging that day to initiate education regarding their primary reason for hospitalization and goals needed for discharge to next level of care.

Assess patient degree of understanding during education by asking them to explain in their own words the details of their plan of care (Teach back method).

Help facilitate and deliver a written discharge plan for the patient that contains: (Teach back method will be utilized to deliver education)

• Reason for hospitalization
• Discuss any tests or studies that have been completed while in the hospital and discuss follow up, if needed.
• Discharge medication list including what to take, how to take them and how to obtain the medication. This includes assessing desire for meds to beds program at Welia for patients.
• Instructions on what to do if their condition changes
• Confirm patient knows where to go, has a plan about how to get to their appointments

Ensure and help inpatient team make follow up appointments, with input from patient and family.

Provide telephone reinforcement of the discharge plan and problem solving 2 – 3 days after discharge.

Assist and collaborate with other nursing team members and social services to contact family members who will share in the care-giving responsibilities.

Maintain a level of med/surg hospital nursing competency to remain knowledgeable and skillful in acute illnesses, related to hospitalization and hospital nursing duties needed to deliver care. This will be done through annual competency validation required for Welia med/surg nursing.

Identifies barriers and works with patient/family to resolve them. Facilitates communication between patient/family and all members of the health care team.

Helps deliver call backs on group of Welia CCM patients who have chronic health conditions to assess needs and begin education of treatment plan and coordination of appointments/services.

Works with the patient/family/healthcare provider to develop, initiate and implement a treatment plan which enhances patient outcomes. Collaborates with patients and family members in decisions regarding the patients care. Follows the patient over time, providing continued education support and resource options. This person will continually utilize the nursing process and collaborate with patient and family to adapt plan to meet changing needs.

Assesses physical, psychological and social dimensions of patients and develops and follows a plan of care for patients. Functions as patient team member working collaboratively with other patient care team members to ensure appropriate level of patient care.

Implements clinical and technical aspects of care and nursing orders in accordance with established policies and procedures. Intervenes with proper technique, procedure and safety precautions to meet individual needs of patient.

Acts as a resource person regarding patient care, specialty area, orientation and teaching of staff.

Assesses, plans, implements and evaluates personal growth and learning development needs.

Possesses excellent communication skills, verbal telephone, written, to ensure accurate and adequate communication.

Participates in and supports research programs and activities; also participates in nursing meetings, committees and other activities which promote the growth and development of nursing and/or patient care.

Functions and supports the Joint Commission standards, Welia Health and Nursing Department policies and procedures.

Considers age-related factors in care, treatment, education, and evaluation of patients ranging from neonates, pediatrics, adolescents, adults, and geriatrics, adolescents, adults, and geriatrics. Applies knowledge of age-related factors appropriately in accordance with professional standards and departmental policies and procedures.

Respects dignity and confidentiality of patients, serving as an advocate, as necessary, and providing a safe and secure environment for the patient. Supports the Patient's Bill of Rights.

Implements quality assurance standards and programs to assure compliance with standards of Joint Commission, as required for full accreditation.

This job description in no way states or implies that these are the only duties to be performed by the employee occupying this position. Employees will be required to follow any other job-related duties requested by their supervisor.

SUPERVISORY RESPONSIBILITIES

The Hospital Nurse Care Coordinator/Utilization Management Specialist will participate in providing work direction, assignment and performance plan development with the leadership team in the Nursing Department.

QUALIFICATIONS To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE

Diploma, A.A. or Bachelor's degree (B. A. or B.S.) from an accredited school of nursing; appropriate and clinical experience and/or training.

Minimum of 1 year experience in acute med/surg hospital nursing clinical experience required.

Experience in Care Coordination, chronic disease management and palliative care preferred.

LANGUAGE SKILLS

Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from patients, families, employees, regulatory agencies, or community. Ability to effectively present information to top management, public groups, patients, families and coworkers.

MATHEMATICAL SKILLS

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Ability to apply concepts of basic algebra and geometry.

REASONING ABILITY

Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.

CERTIFICATES, LICENSES, REGISTRATIONS

Current Registered nurse licensure in the State of Minnesota. BLS certification is required every 2 years, and ACLS certification within two years.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to sit; climb or balance; stoop, kneel, crouch, or crawl; and taste or smell. The employee must occasionally lift and/or move up to 20 pounds, and pushing of up to 200 pounds. Frequent lifting of 40-50 pounds and pulling of 40-50 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally exposed to fumes or airborne particles, toxic or caustic chemicals, and outside weather conditions. The noise level in the work environment is usually moderate. Occasional noise, dusts, mists, violent behavior, contact with communicable diseases, and unpleasant odors. Negligible, precautions should be taken when using oxygen with aerosol.

This job requires exposure to Class I conditions as classified by OSHA.

Welia Health is an equal-opportunity employer.

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