Plans, assesses, re-assess, implements, monitors, and evaluates the options and services required to meet the healthcare needs of the patients using the functions of Utilization Resource Management, Transition of Care, Discharge Planning, and Case Management in order to facilitate: (1) quality of patient care; (2) cost effective utilization and outcome management; (3) communication between patients, families, and members of the health care team; (4) expedition of the movement of patients through appropriate levels of care; 5) safe discharge. Assists with the identification of appropriate providers and facilities throughout the continuum of care, to ensure that resources of both Nicklaus Children's Health System and the patient are used in a timely and cost-effective manner to meet the healthcare needs.
Job Specific Duties
Coordinates medical DCP needs specific to pediatric patients including DME and supplies home health nursing and inpatient/outpatient rehab and other needed medical services.
Screens charts to determine admission & concurrent level of care criteria; monitors daily plan of care. Collaborates to eliminate barriers of efficient delivery of care in appropriate setting & LOS.
Performs admission and concurrent/retro reviews using available third-party critical guideline as applicable. Refers for medical review when system medical necessity criteria are not met.
Coordinates with members of the health care team to assess and identify issues/needs that may have an impact on discharge. Applies cost benefit analysis when planning for discharge needs.
Proactively identifies and resolves delays and obstacles for safe discharge. Seeks consultation from appropriate disciplinary/department to expedite care and facilitates safe discharge.
Communicates with multiple resources and payor entities to identify appropriate vendors for obtaining authorization for ancillary/hospital services to facilitate transition to appropriate level of care.
Collaborates with family, health care team, payors, and providers to achieve appropriate resource management to implement safe discharge plan established by health care team and family.
Assists in identifying and reporting variances in utilization of resources and avoidable days/denials. Works in collaboration with Appeals Management/ Physician Advisor in the appeals process.
Responsible for the appropriate use of software and applications when available and enters case management information accurately and in a timely manner.
Participates in utilization management initiatives/opportunities for improvement through departmental and floor committee assignments, including interdisciplinary rounds and LEAN projects.
Participates actively in complex case meetings to resolve discharge barriers and discuss complex needs of patients to coordinate services post-discharge.
Conducts timey clinical reviews utilizing appropriate resources and critical thinking in applying nationally recognized criteria (InterQual or MCG) to support medically necessary level of care.
Works with the interdisciplinary team for early identification of potential barriers to discharge for resolution.
Submits EQ Health criteria in a timely manner.
Collaborates and communications with the Discharge Coordinator to ensure that the patients' needs for DME, Home Health, post-acute care facility placement, infusion services, etc. are arranged in a timely manner.
Works with the Care Management Transition RN to determine continued patient-centered clinical criteria and needs.
Works with health plans to submit prior authorization forms for identified medications to ensure timely delivery of medications.
Addresses treatment delays, potential denials, and actual denials with the attending physician, members of the healthcare team, and with the Physician Advisor for resolution.
Advocates for the patients who needs community resources and enlists the assistance of the social work department.
Actively participates in initiative to reduce Excess Days and Observed/Expected metrics by taking a proactive approach to utilization management and effectively escalating cases timely that may exceed the GMLOS.
Communicates with residents, attending physicians, and consultants regarding care transition issues.
Communicates with a variety of clinical disciplines and Physician Advisor to clarify and enforce criteria as identified with outside reviewers on determination of their review.
Obtains needed orders from physicians for level-of-care changes as identified for each patient.
Reports quality and risk management concerns to the appropriate department on a timely basis.
Manages patients to ensure patient is in the correct status (Observation, Outpatient-in-a-bed, Inpatient) and ensures that the order matches the appropriate level of care.
Minimum Job Requirements
RN Licensure within the State of Florida or Multi-State Enhanced Nursing License Compact (eNLC) – maintain active and in good standing throughout employment.
1-3 years of pediatric or adult acute clinical hospital experience.
1-3 years of experience in discharge planning, utilization management, case management, performance improvement, managed care reimbursement, or transition of care, care coordination, home health.
Knowledge, Skills, and Abilities
Bachelor of Science in Nursing preferred.
Professional certification as a Case Manager, or certification in CPHM, CPHQ, CCM, or ACM preferred.
5 years of Case Management experience preferred.
Experience in discharge planning, clinical pathways and continuous quality improvement highly desirable.
Basic proficiency in Microsoft Word, Excel, and Outlook.
Able and available to work a flexible/rotating schedule including holidays and weekends.
Able to communicate effectively both verbally and in writing in a clear, concise, and courteous manner.
Bilingual English/Spanish preferred.
Working experience with various technologies, hospital information systems, and other tools used in patient financial services, particularly Cerner.
Able to interpret, adapt and react calmly under stressful conditions in a pleasant manner.
Able to relate cooperatively and constructively with customers and co-workers.
Able to maintain confidentiality of sensitive information.
Able to establish necessary professional relationships and interact effectively with internal and external customers.
Able to work in a fast-paced environment, and effectively manage and use resources to successfully meet the competing deadlines of a variety of tasks and projects.
Able to use logical and analytical thinking to interpret technical data and solve a broad range of problems.
Able to work independently when interacting with organization’s clinical and non-clinical customers and outside vendors/payors.
Demonstrates the ability to relate cooperatively and constructively with customers and co-workers.
Performs duties in a manner to promote quality patient care.
