Clinical Resource Nurse

Clinical Resource Nurse

The Clinical Resource Nurse performs a variety of reviews or clinical functions based on the specific needs of the rural facility. In collaboration with the Director of Patient Care Services, oversees the performance improvement process and quality review functions as well as facilitates the staffing and outpatient schedules. Conducts reviews of patient's medical data to assess appropriateness and medical necessity for admission and continued stay, to assist in assigning an appropriate DRG/LOS that reflects care required by patient, and to facilitate continuing care planning based on patient's needs. Creates monthly statistics reports; implements, leads and monitors a variety of performance improvement projects; responsible for reporting quality metrics; review of documentation and recommendations based on standard of care; proactively identifies potential quality of care issues and work with staff to develop and implement plans for improvement; leads and coordinates PI meetings and works with staff to engage them in the PI process. May perform infection prevention, employee health, risk management and clinical education functions. Educates members of the patient care team on medical necessity documentation guidelines. Works collaboratively with the Patient Care team through regular communication and information sharing. Reviews wound care documentation and photographs. Conducts wound care interdisciplinary team meetings and maintains meeting minutes. Follows up with appropriate personnel as needed related to wound care. Collects data for analysis and report generation. Must be willing to be flexible in assignments and schedule to include weekend work.

Minimum Qualifications

Work Experience

• One year clinical nursing experience with demonstrated leadership skills required.
• Previous leadership experience in quality management of infection prevention preferred.
• Case Management, Utilization Review and/or Coding experience preferred.

Education

• Graduate of a Nursing Program required.

Certifications/Licensure

• Registered Nurse in the State of Kentucky required.

Job Specific Performance Standards

The duties listed below are a summary of the major essential functions of this position. The position may require other duties, both major and minor, that are not mentioned, and specific functions may change from time to time.

• Collaborates with the Director of Patient Care Services to monitor medical records for appropriate documentation.
• Collaborates with Performance Improvement team, rehab, and other committees as required. Prepares reports of quality performance reviews. Reports on performance improvement activities and results of process evaluations to Administration, Performance Improvement Coordinating Committee, Hospital Departments and to Corporate Representatives as appropriate.
• Evaluates and develops goals and objectives for performance improvement and risk management. Consults with Nursing Administration and Hospital Administration and obtains assistance as needed.
• Collects data from patient medical records and other pertinent hospital records necessary to evaluate a process. This includes, but is not limited to: review of all Code Blues and appropriate follow up; review of Critical Results Exceptions and follow up as appropriate; review of Restraints utilized and follow up as appropriate; review of Medication Errors and follow up as appropriate; review of all Rapid Responses and follow up as appropriate; review, organization and compiling of information related to Braden protocol and pressure ulcers; review of Incident Reports and follow up as appropriate; review of documentation related to Chest Pain; review of documentation related to Strokes; review and compiling of information related to Sepsis; review of the monthly ED Transfer Report and explains all out-of-system ED Transfers; Compiling of ED data necessary for periodic review including, such as turnaround times, patients leaving without being seen, substance abuse visits, transfers and admissions; conducting of mortality reviews; review of Hospital Acquired Infections and work to reduce future infections; compiling of information for Hospital Quality Scorecards, both internal and external (for example HCAHPS, MBQIP, Anthem, KHA); compiling of telehealth data as needed; maintenance of Sexual Assault Log; oversite of the FMEA process.
• Accurately enters information on software systems. Prepares and maintains hard copy documentation of audits and reviews as appropriate.
• Plans and implements quality assessment/improvement program to meet hospital's needs. Assists with changes as needed to improve program and insure compliance with regulatory requirements. Assists Department Managers with development and ongoing evaluation of performance improvement and risk management programs and activities.
• Attends and actively participates in Safety and Emergency Management Committees as well as daily safety huddles. Attends and serves as resource on task forces and teams. Attends Performance Improvement Coordinating Committee. Attends and serves on both corporate and internal committees, task force and teams as requested. Serves on professional and civic organizations and committees as hospital representative as needed.
• Reviews applicable Joint Commission standards and other regulatory standards to ensure standards are being met.
• Generates, manages, and updates master nursing schedule according to budget, census fluctuations, call-ins, and leave of absences including but not limited to PTO requests, maternity leave, and Family Medical Leave Act (FMLA) and communicates with Director of Patient Care Services.
• Assists with payroll/time keeping and communicates with the director of patient care services.
• Assists in establishing, revising, and reviewing policies and procedures in collaboration with the Director of Patient Care Services.
• Leads and facilitates Performance Improvement Coordinating Committee meetings.
• Develops reports related to performance improvement with statistical analysis and relays to leaders for identification of trends and opportunities for improvement.
• Performs additional duties both clinical and administrative based on the facility's which includes but is not limited to: coordination of Infusion and Chemotherapy Services; hazardous materials surveillance issues; leading the hospital's Stroke Readiness Certification process; infection prevention, employee health and clinical education functions as necessary.
• Reviews wound care documentation and photographs. Conducts wound care interdisciplinary team meetings and maintains meeting minutes. Follows up with appropriate personnel as needed related to wound care.
• Determines appropriateness of admission, continues stay, and readiness for discharge based on medical necessity following established guidelines of provider and hospital policies.
• Initiates interdisciplinary referrals when appropriate and ensures interdisciplinary referrals have occurred.
• Performs admission and continued stay reviews. As appropriate, participates in performance improvement data collection, evaluation and recommendations for improvement. Refers quality issues to the Department Director.
• Educates internal customers on medical necessity documentation opportunities and reimbursement issues, as well as performance improvement methodologies.
• Interacts effectively with the physician regarding documentation appropriate to diagnosis and severity of illness.
• Communicates effectively with colleagues to clarify issues and collaboratively obtain complete and accurate documentation in the medical record, and participates in Team meetings.
• Refers cases where medical necessity and/or appropriateness of care is unclear to the attending physician, and/or department director.
• Refers cases to the Physician Advisor (PA), when appropriate as outlines in the PA referral policy and procedures.
• Effectively communicates pertinent clinical data to appropriate providers for admission and continued stay certification in collaboration with Department Coordinators, and informs hospital departments/personnel, physician and patient, as indicated, of authorization and/or denials.
• Reports to the department director possible inefficient utilization review of resources.
• Issues denials and indicates and reports these to appropriate agencies, hospital departments and physicians.
• Evaluates denials for appropriateness of appeal, drafts letter of appeal when appropriate or coordinates the appeal process with the Audit & Appeals department and Department Coordinators.
• Accurately enter required information in the medical record and computer system.