Care Transitions RN

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.
• Affords assistance 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.

Additional Job Functions - Acute Rehabilitation

• Responsible for the early identification of potential patients through interdisciplinary team members and medical record review.
• 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.
• 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.
• 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.

Additional Job Functions - Emergency Department

• Collaborates with the ED physicians, admitting physicians, and Bed Management to assist in determining appropriate bed status/classification for all patients.
• 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.
• Completes high risk screening for discharge planning and coordinates with social work and healthcare partners for potential post-acute needs.
• 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.

Additional Job Functions - Utilization Management

• Performs utilization review activities, including concurrent and retrospective reviews as required.
• Determines the medical necessity of request by performing first level reviews, using approved evidence based guidelines/criteria.
• Refers cases to reviewing physician when the treatment request does not meet criteria per appropriate algorithm.
• 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.
• 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.