Position Summary

Promotes and facilitates effective use of hospital resources. Assists with planning an individual comprehensive case management plan addressing patient/family needs and transition to the next appropriate level of care.

Essential Functions

Initially and concurrently assesses all patients within assigned population to include but not limited to admitting diagnosis/medical history, current treatments/therapies, age, payment source, criteria compliance, resources, support systems, anticipated needs,
expected length of stay, appropriate level of service, special/personal needs, and other relevant information.

Assigns working DRG and GMLOS, while concurrently monitoring and managing LOS, as appropriate (determined by medical necessity using Interqual guidelines).

Develops collaborative relationships with patient/family, patient business, nursing staff/leadership, physicians, social workers, care coordinators, and ancillary services to facilitate optimal patient outcomes and efficient movement through the continuum of care.

Prioritizes activities in assigned areas to focus on high risk, high cost, and problem prone areas. Acts as an advocate for patient’s health care needs.

Performs admission and concurrent utilization review in compliance with review requirements for Managed Care contracts, governmental payors (i.e. Medicare, Medicaid, and Champus) and departmental review policies; adheres to Utilization
Management Plan.

Communicates in an appropriate and timely manner with interdisciplinary team to coordinate/evaluate plan of care.

Communicates with third party payers and external care team as appropriate/necessary.
Monitors and evaluates data, fiscal outcomes, and other relevant information to develop and implement strategies for process improvements related to case management activities.

Maintains positive relationships with peers, collaborative team, outside reviewers, and post-acute providers. 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.

Education/Training
Must have one of the following to be in this role:
o Bachelor of Science in Nursing degree (BSN)
o Associate of Science in Nursing (ASN)
o Be a Diploma Nurse with 5 or more years of applicable/related experience.

Licensure/Certification
• Maintains license as an RN in the State of Alabama.
• Maintains current BLS/ healthcare provider certification.

Experience
Three (3) years of experience in chronic disease management, case management, utilization management, or acute clinical care.