Utilization Management RN - FT Days

Number of Positions In Requisition

1

Job Details

Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Wil assist in discharge planning to other levels of care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.

Job Description

Summary
Performs utilization management functions, applying medical necessity criteria to determine the appropriate patient status. Wil assist in discharge planning to other levels of care. Refers cases to the Physician Advisor per departmental procedures. Works collaboratively with members of the Case Management Departments and healthcare team to ensure open lines of communication to ensure optimal outcomes and patient care.

Job Duties

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.
• Collaborates with the Physician Advisor and members of the Multidisciplinary Team to facilitate the Medical Necessity process.
• Applies approved utilization acuity criteria to establish appropriateness of admissions and patient status, and documents findings based on department standards.
• Applies initial DRG for all inpatient admissions and documents appropriately (excluding Jefferson New Jersey).

Minimum Qualifications

• Bachelor’s Degree Nursing, required
• 3 years case management experience, discharge planning or utilization management experience required.
• Knowledge of managed care, governmental and third party payers reimbursement.
• Must be proficient with InterQual and mcg criteria and its application. Strong interpersonal relationships.
• Ability to: prioritize workload; collaborate with others to meet multiple deadlines; communicate effectively orally and in writing; work in a team environment, document in electronic health records.
• Knowledge of the medical, social, economic, and other services provided by other departments or facilities, and the ability to integrate these multidisciplinary treatments for optimal patient care.
• Knowledge and understanding of legislation and regulatory bodies affecting healthcare practices.
• Knowledge of the techniques and the ability to work with a variety of individuals and groups in a constructive and collaborative manner.
• Ability to manage multiple concurrent objectives, projects, groups, or activities, making effective judgments as to prioritizing and time allocation.
• Refers cases to the Physician Advisor or external Physician Advisor per department procedures which require further review or clarification.
• Applies specific relevant medical necessity criteria for all patients to determine the appropriate patient status.
• Documents appropriate medical necessity criteria level of care guidelines subset. (InterQual)
• Follows departmental procedures for Condition 44 downgrades, including medical record documentation, and informing patient and Case Manager.
• Refers cases without documentation of acute level of care to the Physician Advisor.
• Adheres to organizational policies and procedures, identified third party payer contract utilization management workflows and governmental payer processes.
• Complete a medical necessity review for observation status patients in the E.D. via Patient Status Board, at minimum of every 4 hours to determine if patient status has changed or patient can be discharged.
• Applies initial DRG for all inpatients and document in the Care Advance.
• Completes an initial assessment to assess patient’s needs and resources for discharge planning.
• Establishes discharge plan including homecare services, transportation, post-acute facility placements.
• Refers appropriate patients to the E.D. Social Worker for intervention.
• Interface with appropriate Inpatient Case Manager to provide all necessary information.
• Case Management Safety Competencies: Identified patients using the appropriate patient identifiers. Utilizes interdisciplinary collaborative team approach to patient care planning and discharge coordination. Ensures patient medical information is properly communicated to external providers/facilities. Communications discharge plan to patient, family and members of multidisciplinary team. Ensures information is transferred to external providers/facilities.
• Understands the impact of developmental stage on adjustment to illness/trauma. Demonstrates ability to identify adolescent behaviors concerning body image, independence, sexual identity, interference with ability to establish identity, tendency to deny or minimize severity of illness. Allows adult patient to maintain control and involves family in decision-making. Continually considers physical, social and emotional barriers and physical limitations while working with the geriatric patient. Demonstrates understanding of end of life issues.
• assesses and anticipates discharge planning needs to ensure a safe and effective transition to the next level of care for the patient (home, rehab or skilled facility). Involves family/patient/guardian in the decision-making process related to discharge planning. Exhibits effective communication skills while working with neonate, infant, adolescent, and geriatric patient. Demonstrates ability to recognize the signs of physical and/or emotional abuse or neglect to help identify victims. Follows appropriate policy and procedures for reporting of abuse. Demonstrates the ability to identify hearing and sight deficiencies in geriatric population.
• RN - Licensed Registered Nurse_PA - State of Pennsylvania

Additional Qualifications

Physical Demands
Lift and carry 40-50 lbs. Examples: Push/pull patients on bed, stretcher (requires 29 lbs. push force), lateral transfers up to 50 lbs. of the patient's weight. Frequent to continuous standing/walking. Patient transporters can walk 8-10 miles per shift. *Patient care providers may be required to perform activities specific to their role including kneeling, bending, squatting and performing CPR.

Job Description Disclaimer: This position description provides the major duties/responsibilities, requirements and working conditions for the position. It is intended to be an accurate reflection of the current position, however management reserves the right to revise or change as necessary to meet organizational needs. Other responsibilities may be assigned when circumstances require.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Thomas Jefferson University Hospitals, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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