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.

• 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.
• Demonstrates awareness of medical/ legal issues, patient rights and compliance with standards of regulatory and accrediting agencies.
• Serves as a facilitator to physician, nursing staff/leadership and ancillary services (physical therapy, respiratory therapy, clinical social work, care coordination, etc).
• Maintains records and documentation of work performed in a timely, organized, and easily retrievable fashion.
• Reviews current literature on a regular basis; stays current on changes in policies/procedures, maintains reference materials and updates as required, and keeps abreast of relevant reimbursement information.
• Assumes responsibility as a self-directed professional for ongoing education, based on individual identified needs.
• Actively serves on committees and task force teams to promote quality, cost-effective care for patient population.
• Maintains positive relationships with outside reviewers and other payer representatives.
• Forwards identified quality and/or risk issues to appropriate person.

Education/Training

One of the following is required:

• Bachelor of Science in Nursing degree (BSN)
• Associate of Science in Nursing (ASN) + 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.