RN Case Management Utilization Review - Care Coordination

Presbyterian Healthcare Services exists to improve the health of patients, members and the communities we serve. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state’s largest private employer with nearly 14,000 employees – including more than 1,600 providers and nearly 4,700 nurses. Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Turquoise Care) and Commercial health plans.

The RN - Case Management - Utlization Review to provide clinically-based case management to support the delivery of effective and efficient patient care. The role integrates utilization management, care coordination, and transition planning functions. The Case Manager has the overall accountability for a designated case load and plans effectively in order to meet patients needs, manage the length of stay, and promote efficient utilization of resources. In collaboration with the interdisciplinary team, the case manager IV supports the physician in facilitating patient care with the objective of enhancing the quality of patient outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. Preferred candidates with Utilization Review experience in a hospital setting along with RN Case management hospital-based nursing experience.

Interviews and assesses each patient, family or other designated person(s) within 48 hours of admission in order to obtain financial, emotional, physical, social, functional and health care needs in order to define and recommend potential discharge plans, manage patient and family expectations, identify readmission risk and target interventions to reduce risk for readmission, and identify, adjust and manage barriers to discharge. Applies approved clinical criteria to monitor appropriateness of admissions and continued stays to ensure a clear status determination. Refers cases and issues to Case Management Medical Director based on departmental standards. Demonstrates skill in communicating with physicians the necessary Documentation required to demonstrate medical necessity. Elevates to Supervisor and/or Medical Director all patients not meeting criteria after discussion with physician. Demonstrates skill in educating patient, family and interdisciplinary team regarding post-acute care options, status determination, and other care coordination services. Develops implements, coordinates, monitors and evaluates preliminary and final discharge plans with the interdisciplinary team, patient and family. Arranges and/or facilitates identified discharge needs and services of patients and ensures timely intervention to prevent delays in service and transition of care. Ensures all elements of the plan of care have been communicated to the patient/family and members of the healthcare team to assure continuity of care. Participates and facilitates care progression in daily multidisciplinary rounds and addresses target length of stay with health care providers to achieve complete delivery of services within prescribed timeframe. Monitors length of stay and takes action to mitigate overutilization and elevates to medical director as needed. Presents and actively participates in complex rounds, discharge planning huddles, process improvement teams, department specific initiatives and department meetings. Identifies patients and families with complex psychosocial issues and refers them to the Social Worker as appropriate. Demonstrates skill and success in collaboration with Social Work partner. Facilitates and leads patient/family and provider care conferences as needed. Documents results of assessments, status assignment, and interventions and discharge planning in the medical record according to departmental policies and procedures. Ensures safe care to patients adhering to policies, procedures, and standards within budgetary specifications, including time management, supply management, productivity and accuracy of practice. Promotes individual and departmental professional growth and development by meeting requirements for and facilitating continuing education, skills competency. Supports departmental based goals which contribute to the success of the organization. Serves as a mentor, preceptor, mentor and resource to less expe