Portal of Entry (ED) Utilization Management Nurse- 32hr- Onsite

About the role

The Portal of Entry Utilization Management Nurse (POE) at The Center Connecticut Children’s Center for Care Coordination supports the Care Management program by developing and maintaining processes for determining the defensible hospitalization status based on regulatory and reimbursement requirements of various commercial and government payers. This role supports the physician and other qualified practitioners in determining the defensible patient class at the time of admission in the Emergency Department.

Responsibilities

• Performs chart review of assigned patients to identify quality, timeliness, and appropriateness of patient care.
• Conducts hospitalization reviews based on appropriate guidelines.
• Uses these criteria to screen for defensible level of care based on medical record documentation.
• Escalates cases as appropriate for secondary review.
• Adheres to CMS guidelines for utilization reviews as evidenced by utilization of the relevant guidelines and appropriate referrals for secondary review.
• Identifies, develops, and implements strategies to reduce length of stay and resource consumption in conjunction with discharge planning staff.
• Provides consultation and education to physicians and other qualified practitioners regarding medical record documentation necessary to support the ordered level of care.
• Performs and documents initial / admission medical necessity review for all points of entry.
• Communicates initial medical necessity review results with emergency department and admitting providers as necessary to support defensible admission status orders.
• Proactively collaborates with emergency department providers and staff to identify patients likely to require hospitalization.
• Works in conjunction with emergency department social workers and other staff to identify and secure available and necessary services to support clinically appropriate hospital admission avoidance.
• Obtains information from patient, caregivers, providers of services, insurance company, benefits administrators and others as necessary.
• Conveys benefit data and options, programs and other forms of assistance that may be available to the patient, and negotiates for services as indicated.
• Communicates pertinent reimbursement information to healthcare team while observing patient right to confidentiality.
• Verifies in-network verses out-of-network benefits and communicates data to the patient and healthcare team as indicated.
• Performs pre-admission reviews.
• Performs prospective medical record review of patients scheduled for outpatient/inpatient procedures scheduled in the hospital setting.
• Screens scheduled patients to ensure that they are scheduled in a defensible utilizing industry-accepted level of care criteria.
• Reviews and interprets the patient’s medical record to supply appropriate information to third-party payers as necessary.

Qualifications

• Education: Bachelor of Science in Nursing (BSN)
• Experience: 3 years of nursing experience in a healthcare setting, preferably in pediatric nursing and Utilization Review.
• License and Certification: State if Connecticut Nursing License.
• Knowledge: Demonstrate working knowledge of how to interpret and apply medical care criteria. Knowledge of community resources, treatment options, home health availability, funding options and special programs.
• Skills: Coordinates management of care for a specified patient population; follows patients throughout the continuum of care and ensures optimum utilization of resources, service delivery and compliance with hospital standards. Provides ongoing support and expertise through comprehensive assessment, care planning, plan implementation and overall evaluation of individual patient needs. Skilled in the operation of the computer including proficiency in Microsoft Office Word, ability to use/update Excel spreadsheets and ability to navigate EPIC.
• Abilities: Self-directed/motivated, organized, diplomatic and team-oriented. Function in a high energy, fast moving environment. Maintain flexibility as determined by acuity of medical unit. Prioritize case load. Collaborate with various disciplines. Communicate effectively and efficiently. Prioritize and manage multiple tasks. Excellent written and verbal communication skills.