The RN Float Case Manager and Utilization Review Nurse provides coverage for an RN Case Manager or RN Utilization Review Nurse. The RN Float Case Manager and Utilization Review Nurse is assigned to function in the role of either a RN Case Manager or RN Utilization Review Nurse, as provided below. When functioning in the role of a RN Case Manager: In collaboration with the interdisciplinary team, provides care coordination services evaluating options and services required to meet an individual's health care needs to promote cost-effective, quality outcomes. Serves as a consultant to members of the health care team in the management of specific patient populations. The RN case manager role integrates the functions of utilization management, quality management, discharge planning assessment, and coordination of post-hospital care services, including transfers to an alternative level of care. When functioning in the role of a RN Utilization Review Nurse: The RN Utilization Management Specialist coordinates communication with admitting financial counselors, case management team, providers, patient financial services, and payers to ensure all services provided by the hospital are authorized by appropriate payer. The RN Utilization Management Specialist confers and reviews with physicians on medical admitting information to assess medical necessity and uses evidence-based criteria to consider the anticipated length of stay, level of care, intensity of service to support access to services. The RN Utilization Management Specialist facilitates timely transmission of admission, concurrent and discharge reviews to the appropriate payer to ensure all days are authorized and documented. Clinical reviews and continued stay authorizations will be documented in the appropriate electronic system.

Essential Duties:

• RN Case Manager - Position Accountabilities 1. Able to effectively manage a minimum case load of 18-20 patients. 2. Completes initial discharge planning evaluation within one business day and identified high risk indicators for discharge planning and/or need for psychosocial interventions and integrates with SW Case Manager/Discharge Planning Coordinator as needed. 3. Actively participates in multidisciplinary rounds and discharge huddles as required, focusing on targeted discharge date and patient care progression. 4. Identifies high risk indicators for discharge and/or needs for psychosocial interventions and involves Social Work team member as indicated. 5. Analyze and interpret data in collaboration with patient, family, physician, health care team to develop a plan of care. 6. Develops and implements the following referrals/ placements/interventions: LTAC, subacute, home care, home care with therapy services, home care with DME services, Durable Medical Equipment/oxygen, infusion therapy, wound care, and acute to acute hospital transfers. 7. Notifies attending physician and medical physician advisor of any discharge planning barriers or issues, assist with coordinating Peer to Peer reviews, and documents interactions and outcomes in the electronic case management system. 8. Demonstrates collaborative working relationship with social workers to ensure patient psychosocial needs are met while coordinating care (ie planning and implementing discharges to private duty care, skilled nursing facilities, end of life, hospice, and palliative care. 9. Coordinates acute to acute transfers as requested by payers to return patients to in network facilities. 10. Adheres to regulatory requirements as defined by CMS Conditions of Participation and /or health plan, serving regulatory letters as indicated (ie MOON, HINN, ABN, and Code 44). 11. Serves as a consultant to the health care team to identify financial issues that may affect care. 12. Participates in the education of health care team members on current healthcare issues impacting practice patterns and reimbursement. 13. Educates physicians and health care team on patient status, as appropriate. 14. Delegates and supports team members to facilitate discharge planning. 15. Adheres to hospital and department protocols, workflows, policies, procedures, standards and competencies for clinical role. 16. Participates in InterQual competency testing as requested by department director. 17. Participates in hospital quality improvement processes and helps identifies opportunities to improve care. 18. Strives to support and contribute to the success of the department outcome metrics, key performance indicators and /or department goals and objectives. 19. Identifies compliance and ethical issues and reports appropriately. 20. Work with post acute services to address educational needs to ensure a safe discharge plan. 21. Identifies and creates discharge planning solutions, proposes alternative treatment options to ensure a cost effective and efficient plan of care. 22. Enters information concurrently into the electronic medical record and utilizes case management module to update, track and record outcomes as indicated. 23. Participates in appeal process. 24. Supports the needs of the department with other duties as assigned and/or delegated.
• RN Utilization Review Nurse - Position Accountabilities 25. Validates patient registration status with physician order against medical necessity screening criteria 26. Applies evidence based medical necessity screening criteria as defined by the Utilization Review plan. 27. Performs admission, continued stay and discharge reviews. 28. Reviews daily surgery schedule for planned admissions to ensure that services are screened for appropriate level of care status. 29. Ensures that all bedded outpatient services that require admit to hospital are screened for appropriate level of care status. 30. Provides clinical review to health plans as required by the health plan and/or the Utilization Review plan. 31. Follow up on all payer authorization determinations to ensure completion prior to closure of record. 32. Notifies medical physician advisor when patient’s medical condition does not meet admission or continued stay criteria as defined by 42 CFR 428.30 and/or health plan. 33. Coordinate and facilitate concurrent Peer – to – Peer calls as needed. 34. Adheres to regulatory procedures: MOON, IMM Discharge, Appeal/HINN, Code 44, Two Midnight Rule, Inpatient Only Procedure. 35. Responds timely to payer requests for clinical reviews and completes verbal reviews as needed, including the TAR process as defined department protocol. 36. Communicates with payers when patient status changes from observation/extended recovery to inpatient to obtain authorization for inpatient stay. 37. Initiates a call to payers to confirm receipt of clinical reviews and request authorization of all days upon discharge. 38. Documents communication with payers and outcomes of discussions in electronic systems. 39. Inputs authorization data into spreadsheets per protocol. 40. Assists with denial management to identify opportunities to improve department processes 41. Represents the department in a positive and professional manner 42. Demonstrates collaborative working relationships with case managers and payers to ensure authorizations are obtained and current. 43. Maintains awareness of payer/reimbursement practices and requirements. 44. Identifies opportunities to improve department workflow and process regarding payer communication. 45. Identifies compliance and ethical issues and reports appropriately. 46. Assists with orientation of new staff. 47. Participates in hospital quality improvement processes and helps identifies opportunities to improve care. 48. Identifies and documents avoidable delays in the electronic system. 49. Strives to support and contribute to the success of the departments outcome metrics, key performance indicators and /or departmental goals and objectives. 50. Documents outcomes in the medical record. 51. Adheres to hospital and departmental protocols, workflows, policies, procedures, standards and competencies for clinical role. 52. Adheres to the mission, vision and values of the organization. 53. Performs other duties as requested/assigned.

Required Qualifications:

• Req 3 years Clinical experience.
• Req Knowledge of case management principles and healthcare management.
• Req Problem solving skills and ability to multi-task.

Preferred Qualifications:

• Pref Bachelor's degree Nursing
• Pref 1 year Case management or utilization review experience within the last three years preferred.

Required Licenses/Certifications:

• Req Registered Nurse - RN (CA DCA)
• Req Basic Life Support (BLS) Healthcare Provider from American Heart Association
• Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)