Job Summary:
SNF Post-Acute Utilization Management (UM) Care Coordinators are health care professionals who receive incoming referrals for patients primarily in SNF /postsub -acute care facilities with the goal of determining if the patient meets criteria, assuring appropriate level of care, quality of care, and efficient, cost-effective utilization of available resources. If the patient does not meet criteria, RNs arrange peer to peers, issue denial letters, and outreach the patient/families to assist with discharge planning/resources/schedule PACT appts). They independently assess needs and develop a plan of care for patients with complex discharge planning needs; serve as expert resource consultants for physicians and other health care team members in discharge/transition/and coordination of internal and community resources; support the evaluation and improvement of systems of care to support the optimal utilization of health care resources, while maintaining quality patient care.

Essential Responsibilities:

• Independently review, available clinical, medical, and nursing information to determine if there is a need for admission to a post-acute level of care. The consistent use of the clinical support system (approved guidelines, UM physician, MCG, and other tools) is expected. Review will be performed telephonically and electronically (Allscripts, fax, email, or other similar programs). If the patient does not meet criteria, RNs arrange peer-to-peers, issue denial letters, and outreach the patient/families to assist with discharge planning/resources/schedule PACT appointments.


• Proactively and independently, complete assessments which are thorough, timely, age appropriate, and reflect psychosocial support systems, care needs, benefit array, level of care determinations, and document same for designated population of patients. Responsibilities include assessment/analysis of the effectiveness of existing support systems, health care team encounters/management plans and interventions, the patients/familys ability and willingness to comply with care plan, and to formulate recommendations for both the patient/family and health care team.


• Oversee and facilitate work with patients, families, and health care teams to develop a hospital plan of care that creatively optimizes the use of all available and appropriate resources to support the best plan of care for the unique and particular needs of each patient on a case by case basis.


• Develops and maintains an expert level of knowledge and skills related to utilization management, and coordination of care guidelines. Identifies, documents, and reports quality of care issues. Recognizes, documents, and acts upon mis-utilization of health care resources. Supports case management by identifying and referring potential cases to appropriate case areas. Supports quality improvement activities by identifying and reporting potential and actual quality of care issues.


• Serves as an advocate for the patient and family as well as for the health care system in matters of optimal use of health care resources. This includes acting on behalf of the health care system in the issuance of notices of denials and on behalf of the patient/member assuring they are informed and understand their rights and the appeal processes.


• Assists in maintaining a database to monitor utilization management activities, cost avoidance activities, and patient outcome information in compliance with organization and governmental regulations.


• Performs other duties as requested or program evolves.

Basic Qualifications:Experience

• Minimum two (2) years of acute hospital or post-acute experience.

Education

• BSN OR RN with documented two (2) years of recent experience in the past five years in the areas of utilization, discharge planning, community health, hospice, or home health in lieu of a degree (BSN).
• High School Diploma or General Education Development (GED) required.

License, Certification, Registration

• Registered Nurse License (Colorado) required at hire
  

• Basic Life Support required at hire
  

Additional Requirements:

• Demonstrated ability to interrelate with physicians, nurses, and patients.
• Good clinical judgment to assess the needs of patients as related to levels of patient care.
• Knowledge of the principles of patient teaching, disease prevention measure, physical assessment and appropriate utilization of acute hospital resources.
• Knowledge of Medicare and Medicaid regulations, hospital, nursing facility, home health and hospice eligibility requirements.
• Knowledge of Kaiser insurance products.
• Familiarity with and ability to use a personal computer.

Preferred Qualifications:

• Minimum twenty-five (25) years of acute hospital or post-acuteSNF experience with progressive levels of responsibility.
• Minimum Documented three (3) years of recent experience in area of utilization, discharge planning, hospice, and/or community or home health nursing.
• BSN preferred.

Home health/ SNF experience preferred

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