Five years recent relevant clinical experience in an acute care facility required.
Strong Interpersonal skills and ability to work with patients, families, providers, peers, and other departments required.
Ability to use word processing and computer spreadsheets and other computer-based programs required to do the job. Excellent communication and problem-solving, and critical thinking skills.
Strong patient education abilities.
Knowledge of and experience with InterQual® Level of Care Criteria, experience in automated InterQual® preferred.
Knowledge of the regulatory environment, including Medicare Conditions of Participation, DNV standards, HIPAA, and reporting requirements.
Submits appeals in a timely manner, upon request by the Director.
Initiates discharge planning on assigned patients within 24 hours of admission. Revises discharge planning as indicated by changes in the patient’s condition and circumstances.
Arranges for the post-discharge needs of patients.
Clearly and accurately documents all patient/family interventions and interactions.
Monitors for the efficient use of resources and reports to Director when there are actual or potential sources of under- or over-utilization.
Collaborates with providers, nurses, patients, families, and other care providers in the development and implementation of patient care plans, including discharge planning, across the continuum of care in support of the GCRMC Mission.
Communicates with providers regarding patient status and assists him/her in ensuring proper placement of patient.
Conducts utilization review using nationally recognized medical necessity criteria and documents the review.
Refers cases for second level reviews when medical necessity criteria are not met.
Demonstrates familiarity with the various levels of care and community resources available for each patient and the providers of these different aspects of care.
Actively participates in interdisciplinary treatment planning rounds.
Utilizes innovative methods to facilitate development and implementation of discharge plans.
Makes self available as resource to nursing staff. Provides learning experiences to strengthen and expand the staff’s expertise.
Participates in infection control activities by screening, monitoring, and reporting individual cases and/or trends to the infection control nurse.
Performs utilization management functions as required by payer source.