RN Case Manager

Position Summary:

Works collaboratively to coordinate and screen for the appropriateness of Continued stays. Makes recommendations for alternate levels of care when the patient does not meet the medical necessity for Inpatient hospitalization. Interacts with the family, patient and other disciplines to coordinate a safe and acceptable discharge plan. Functions as an indirect caregiver, patient advocate and manages patients in the most cost-effective way without compromising quality.

This role involves obtaining insurance authorizations and closely reviewing medical records and patient cases to determine the appropriateness of treatments and ongoing stay. The Utilization Review RN collaborates with physicians, nurses, and other healthcare professionals to coordinate patient care and ensure compliance with healthcare policies, regulations, and insurance guidelines.

Essential Functions:

• Plans, develops, assesses & evaluates care provided to patients.
• Collaborates with physicians, other members of the multidisciplinary health care team & patient/family in the development, implementation & documentation of appropriate, individualized plans of care to ensure continuity, quality & appropriate resource use.
• Recommends alternative levels of care & ensures compliance with federal, state & local requirements.
• Assesses high risk patients in need of post-hospital care planning.
• Develops & coordinates the implementation of a discharge plan to meet patient's identified needs.
• Communicates the plan to physicians, patient, family/caregivers, staff & appropriate community agencies.
• Reviews, monitors, evaluates & coordinates the patient's hospital stay to assure that all appropriate & essential services are delivered timely & efficiently.
• Participates in the Bed Huddles & carries out recommendations congruent with the patient's needs.
• Acts as a liaison between in-patient facility & referral facilities/agencies & provides case management to patients referred.
• Refers patients to community resources to meet post hospital needs.
• Coordinates