Position Summary
RN licensed in the State of Florida currently, with at least three years plus in utilization review. This role will be PRN and considered vital to covering staff on vacation, holidays, varied shifts, and the right person needs to have some flexibility. Promotes and facilitates effective management of hospital resources from admission to discharge, collaborating with the assigned clinical team to identify patients most likely to benefit from care coordination services to include assessing patients’ risk factors and the need for care coordination, clinical utilization management and the transition to the next appropriate level of care. The position may be hybrid in the near future but candidates must live in the Central Florida region.
Responsibilities
Initially and concurrently assess all patients within assigned population to include, but not limited to:
Accurate medical necessity screening and submission for Physician Advisor review
Care coordination that includes admitting diagnosis/ medical history, current treatments, age, payment source, resources, support systems, anticipated needs, expected length of stay, appropriate level of service, special/ personal needs, and other relevant information
Assignment of initial DRG to determine GMLOS, while concurrently monitoring and managing LOS and transition planning as appropriate through assessment and reassessment and the application of InterQual guidelines
Leading and facilitating multi-disciplinary patient care conferences
Managing concurrent disputes
Making appropriate referrals to other departments
Identifying and referring complex patients to Social Work Services
Communicating with patients and families about the plan of care
Leading and facilitating Complex Case Review
Identification and documentation of potentially avoidable days
Identification and reporting over and underutilization
Ensures compliance with all regulatory standards including Federal, State, Local and Joint Commission with review requirements for managed Contracts, Medicare, Medicaid, and Campus related to admission and continued stay approval
Adheres to Utilization Management Plan
Integrates National standards for care management scope of services including:
Utilization Management supporting medical necessity and denial prevention
Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and appropriate level of care
Education provided to physicians, patients, families, and caregivers
Communicates appropriately and timely with the interdisciplinary team and third-party payers
Prioritizes activities in assigned areas to focus on high risk, high cost, and problem prone areas
Develops collaborative relationships with patient business, nursing, physicians, and patient/family to facilitate efficient movement through the continuum of care
Monitors and evaluates data, fiscal outcomes, and other relevant information to develop and implement strategies for improvement
Maintains positive relationships with outside/onsite reviewers and other payer representatives
Identifies cultural, socio-economic, religious, and other factors that may impact treatment
Involves patient’s family in the development of the treatment plan as appropriate while explaining procedures, therapies, systems treatment plans, and discharge plans in age/developmental/educational specific terms to patient/family
Reviews patient’s discharge plan at multidisciplinary meetings and/or staffing to facilitate communication with other healthcare team members
Prioritizes workload to manage multiple priorities while using problem-solving skills to meet goals
Enhances professional growth by participating in educational programs, current literature and/or workshops
Possesses excellent interpersonal skills and ability to work in a team environment
Respects the rights and privacy of others and holds staff member information in strict confidence
Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state and local standards
Maintains compliance with all Orlando Health policies and procedures
Qualifications
Education/Training
Graduate of an approved school of nursing
Licensure/Certification
Must hold and maintain a current Florida RN license
Handle with Care (HWC) Certification required for the Behavioral Health Unit within 90 days of hire. The Handle with Care training and education will be provided onsite to all team members
Experience
Three (3) years of experience in chronic disease management, care management, care coordination, utilization management, or acute clinical care