Utilization Review Nurse - Warm Valley Health Care

POSITION SUMMARY:

Provides specialized case management/care coordination for patients requiring unique health care needs at Warm Valley Health Care (WVHC). Maintains a process of continuous patient assessment, care planning and coordination, and service integration. Strives to improve the quality of care, decrease the fragmentation of care, facilitate the integration of medical, psychological, developmental, educational, social, and financial needs, enhanced patient self-care, improved health outcomes. Provides ongoing education to clinical staff for the patient navigation process/resources and policies related to the referral process of the Purchased and Referred Care (PRC) department, with emphasis on cost-efficient clinical management.

DUTIES AND RESPONSIBILITIES

• Functions as a member of PRC team, involved in continuous quality improvement as an approach to manage patient care. Constantly monitors cost utilization and referrals to Medical Resources.
• Reviews outpatient and urgent care consultations/referrals to determine if referral meets established criteria of current priority level, monitor for alternate resources available, justification for services requested, and appropriateness of referral request. Collaborate with PRC team, Medical Providers to determine medical necessity and appropriateness.
• Collaborates with other facilities to determine medical necessity and appropriateness of level of care using Centers for Medicare & Medicaid Services (CMS) approved criteria for inpatient and outpatient referred care encounters. Checks the severity of illness, intensity of service and discharge criteria on referred patients.
• Works in close coordination with the Resource Management Committee (RMC) medical providers and team to maintain provider specific statistical data regarding consult reports and ensures all approved consults are completed in a timely manner. Ensures deferred referrals are managed and returned to CMO for final decision for approval or denial, and reviews all denied referrals for potential alternate resource availability or referred to Medical Resources to initiate application process for state or federal programs.
• Maintains system for tracking referred patients for admission to other healthcare facilities and perform chart reviews to determine timeliness of requested service in order to facilitate the return of patients to WVHC.
• Provides technical assistance to PRC staff for clinical issues for assigned patients.
• Responds to insurance providers, third party agencies to insure maximum reimbursement to minimize WVHC costs on clinical issues.
• Works in coordination with the PRC Supervisor to implement and monitor CHEF program for PRC department; including case reviews and assures documentation is prepared and submitted in a timely manner for re-imbursement.
• Participates in case management conferences between various disciplines, families and agencies.
• Monitors patient status through continuum of services provided and ensure Primary Care Teams are notified of progress of patient referral. Determines if services are being delivered as planned, if services are meeting needs. Reassesses at appropriate intervals to determine if the patient's condition or situation has changed, and revises goals and plans of services accordingly.
• Works closely with Business Office Manager, PRC Supervisor, and Benefits Coordinator to maximize the use of alternate resources for referred care payment, protecting PRC funds for those patients who do not qualify for alternate resources, and/or PRC as secondary payer.
• Reviews all Urgent Care visits from the previous night/weekend to assist patients in assuring follow up needs are met.
• Runs reports from EMR and tracking software to identify the following high- risk patients this includes but is not limited to: positive pregnancy tests, OB deliveries that occur in the Urgent Care, patients' who have frequent visits to the Urgent Care, new onset of Hepatitis C, HIV, Cancer and Chronic Kidney Disease. Makes contact with the primary care teams to coordinate care with the patient's Primary Care Provider (PCP).
• Completes risk stratification utilizing validated stratification tool. Serves as an advocate for the patient and their families.
• Provides education to WRSU Primary Care Teams as needed regarding rules and regulations of PRC eligibility and required justification and referral processes.
• Ensures direct patient care supplies are available when needed.
• Assists with Durable Medical Equipment (DME) procurement upon patient's hospital discharge or primary care provider (PCP) request.

QUALIFICATIONS:

• Minimum: Graduate of an Associate's Degree Registered Nurse (RN) from Accredited Nursing Program
• Valid Nursing License
• Must possess excellent written and oral communication skills
• Current BLS, ACLS, and PALS certification
• Current with Continuing Medical Education (CME)