Registered Nurse - Care Coordinator - Utilization Review

Primary Purpose

Establishes and maintains an efficient, cost effective care management process by determining patient financial and medical eligibility, medical necessity, and by developing, implementing and monitoring individual patient plans of care and communicating these plans to patients, families, and Parkland staff to ensure quality patient care throughout the healthcare continuum and compliance with program/Parkland policies and procedures.

Responsibilities

• Counsels patients and families regarding financial counseling as appropriate.
• Mobilizes resources and coordinates the effort to the health care team to achieve a positive patient transition to appropriate next level of care.
• Communicates plan of care to patient and their family providing updates and reassesses the plan of care to determine effectiveness.
• Completes appropriate coordinator management documentation.
• Evaluates the plan of care at appropriate intervals to determine effectiveness in meeting outcomes and goals.
• Works with nursing and other disciplines to ensure that discharge needs, including teaching, are met.
• Collaborates with the healthcare team to identify 'best' practices for achieving patient outcomes.
• Develops reporting mechanisms to communicate outcomes to physicians and other members of the health care team.
• Applies approved utilization criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards.
• Makes recommendations for performance improvement opportunities by the health care team.
• Communicates with Care Management team to facilitate covered-day reimbursement certification and/or authorization for assigned patients.
• Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed.
• Transitions patients through the health care system based upon individual and patient population needs.
• Engages in special projects and serves on committees, as assigned.

Minimum Specifications

• Education: Graduate of an accredited school of Nursing.
• Experience: Two (2) years of hospital or community based patient care nursing, preferably in assigned clinical area.
• Certification/Registration/Licensure: Current, valid RN license or temporary RN license from the Texas Board of Nursing; or, valid Compact RN license. Must have current healthcare provider BLS for Healthcare Providers certification from one of the following: American Heart Association, American Red Cross, Military Training Network.
• Required Tests for Placement: Skills or Special Abilities: Provides care to assigned patient population in accordance with the current State of Texas Nursing Practice Act, established protocols, multidisciplinary plan of care, and clinical area specific standards. Must be able to communicate and collaborate effectively with a diverse group of patients, families and healthcare staff. Must be able to demonstrate a working knowledge of specific patient populations, and be able to demonstrate knowledge of disease processes affecting this group. Must be able to demonstrate a working knowledge of PC operations and the ability to use word processing software in a Windows environment. Must be able to demonstrate a working knowledge of the laws and regulations governing Medicare, Medicaid and community-based funding sources. Must be self-directed and capable of priority setting and problem solving. Must be able to demonstrate patient centered/patient valued behaviors.