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Regional Medical Center Case Manager/Resource RN in Manchester, Iowa

TITLE: Case Manager/Resource Nurse

DEPARTMENT: Emergency Department

POSITION DESCRIPTION: This position is responsible for establishing, coordinating, and maintaining the process to increase patient throughput to the most appropriate level of care while facilitating interdisciplinary care across the continuum for the ED. This position assesses, plans, implements, monitors and evaluates options and services to expedite medically appropriate cost-effective care that meets patient health needs.

QUALIFICATIONS:

  • Registered Nurse with a current license to practice in the State of Iowa

  • BSN preferred

  • BLS certified

  • Child and Dependent Adult Mandatory Reporter Training required

  • Self direction, organization, priority setting, critical thinking, problem solving and interpersonal skills to promote teamwork and patient care management starting at the time the patient presents to or accesses the hospital is required.

  • Behavioral health (mental health and/or substance abuse) nursing experience is preferred.

  • Knowledge and/or familiarity with community resources, Iowa Judicial Branch, outside professional agencies, federal and state regulations as well as understanding the financial structure of health plans and delivery systems is preferred.

ACCOUNTABILITY:

Reports to the ED coordinator. Works collaboratively with providers and staff, the Utilization Review Department on Med-Surg/ICU and RFH Patient Resource Specialist.

POSITION REQUIREMENTS:

  • Begins utilization review starting at the time patients access the hospital in the emergency room.

  • Conducts patient/family assessment and management, resource management, identifying patients appropriate for Inpatient Admission, Observation, or Outpatient status, care facilitation, discharge planning with referral to all levels of care, and other related duties specific to the defined patient population.

  • Acts as a resource to ED staff and providers regarding appropriateness of admission, levels of care (including related documentation requirements and observation vs. inpatient requirements), quality of care concerns and criteria/guidelines/protocols utilized in care planning and resource utilization (ie. Milliman).

  • Completes initial assessment of the clinical condition of emergency room inpatient admissions for national evidenced based core measures.

  • Coordinates and facilitates the appropriate level of care through multi-disciplinary coordination including other mental health facilities, inpatient admission, civil commitments, care facilities, health care providers, and other community support agencies.

  • Assist with other patient care processes within nursing scope of practice as assigned.

  • Serves as a back-up for case management and/or social worker in other areas of the hospital.

  • Plans with the patient, family or caregiver, providers, payers, and community to maximize health care responses, quality and cost effective outcomes

  • Facilitates communication and coordination of care between members of the health care team, involving the patient and caregiver in the decision-making process in order to minimize fragmentation in the services within the healthcare delivery system

  • Focuses on transitions of care to the next appropriate level of care; coordinate transition of care with additional health care providers and services associated with discharge or return home that is effective, safe, timely and complete

  • Educates the patient, family and/or caregiver about their disease, medication and treatment

  • Completes readmission risk assessment to identify high risk patients and collaborate health care team to focus efforts to avoid. If readmission occurs, completes drill down and communicates findings with health care team to avoid future readmissions

  • Collaborates efforts that focus on moving the patient to self-care whenever possible

  • Manages resource utilization and reimbursement services

  • Verifies coverage and benefits with health insurers

  • Reviews inpatient medical records daily to assess admission criteria, identifying qualifiers and suggested length of stay using standard care guidelines

  • Advocates for both the client and the payer to facilitate positive outcomes for the client, the health care team and the payer

  • Reviews and seeks health care team consultation regarding incoming referrals for skilled care

  • Identifies practice improvements and use evidence based data to influence needed practice change

  • Assists with writing, reviewing, revising and implementing Utilization Review/Case Management policies and procedures with appropriate approval

  • Assists with collecting, analyzing and reporting quality data

  • Presents UR/Quality data at appropriate committee

  • Willing to accept UR/CM consultation phone calls outside scheduled working hours

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