PATIENT CARE PLANNER-PRN

Job Title

Pay Range for this position is $38.62-$57.93 DOE

Essential Functions and Basic Duties

• Tracks patient cases from admission to discharge. Ability to identify patients who are likely to suffer adverse health consequences upon discharge, needing coordination of support services, and follow-up care based on diagnosis and level of acuity.
• Conducts timely evaluations for all patients identified by their physician, patient, nursing, family, or friend requests, or discharge planner inquiry as needing discharge planning.
• Ability to develop an individualized care plan for patients needing patient care planning support.
• Ability to use critical thinking skills supporting patients in accessing all necessary applicable resources for follow-up care:
• From admission (regardless of status) ensures that patients are "pre-qualified" for hospital admissions.
• Continued admission (regardless of status) ensures that patients are "re-qualified" for hospital admissions.
• Conducts appeals on behalf of the patient and family (at the time of service and for hospital stay denials).
• Develops discharge plans for patients to the most appropriate plans of care understands the resources available and advocates for the patient for those resources.
• Understands Lifeline, Transition Care, Swing Bed, Home Health, Hospice, Nursing Home Services, and can discern and explain which resource may be best for a specific patient based on diagnosis and level of acuity.
• Fully understands transitional care and how that service works with a Critical Access Hospital.
• Ability to advocate for patients and negotiate with physicians and ancillary staff for patients.
• Ability to advocate for patients with insurance companies and CMS for additional services.
• Expert at InterQual and/or Millimen clinical decision-support criteria.
• Ability to identify patients at risk for abuse, depression, falls, or other conditions. Follows the proper procedures for reporting.
• Gathers pertinent clinical information and applies and interprets criteria to ensure medical necessity, covered benefits, participating providers, and appropriate services.
• Advocates that the patient is placed in the appropriate level of care and program.
• Interfaces with program staff to facilitate a smooth transition at the time of transfer or discharge.
• Monitors patient charts and records to evaluate care concurrent with the patient's treatment.
• Reviews treatment plans and status of approvals from insurers.
• Facilitates and coordinates discharge planning and works towards the reduction of preventable hospital admissions, re-admissions, etc.
• Works closely with the Revenue Cycle Department to ensure the insurance precertification process is complete and to update the denial log statistics on an ongoing basis (at least weekly), and initiate appeals through telephone or written communication within 7 to 10 days of denial.
• Collects and compiles data as required and renders with applicable hospital policies as well as state and federal guidelines.
• Communicates with the clinical care team on any outstanding or concerning findings during utilization review, including, but not limited to: failure to meet medical necessity, inappropriate admission status, etc.
• Communicates with providers to obtain any medical record documentation necessary to perform utilization review.
• Documents any UR needs or notes into the Electronic Medical Record (EMR).
• Administers or participates in audits of programs to ensure agency compliance with utilization review regulations.
• Performs other duties as assigned.

Organization-Specific Performance Expectations, Duties, and Responsibilities:

• Demonstrates full commitment to the CHOICE values of MRH and consistently represents the organization in a positive, professional manner.
• Establishes and maintains effective verbal and written communication, fostering positive working relationships with patients, staff, and vendors.
• Adheres to the MRH attire and dress code in accordance with organizational policies and procedures.
• Exhibits initiative and self-motivation; maintains a consistent level of productivity and manages time and responsibilities effectively.
• Completes all required annual education, training, in-services, and licensure/certification updates; actively participates in departmental and organizational meetings or reviews meeting minutes as required.
• Maintains strict patient confidentiality at all times.
• Reports to work punctually and completes assigned duties within established timeframes.
• Actively contributes to departmental and organization-wide performance improvement and continuous quality initiatives.
• Ensures compliance with all regulatory requirements, maintaining adherence to departmental, hospital, state, and federal standards and policies.
• Follows all infection control, safety, and risk management procedures to maintain a safe environment for patients, the public, and staff.

Qualifications

• Must be at least 18 years of age (21 for positions requiring driving, with a valid driver's license).
• Must be legally authorized to work in the United States.
• Must successfully pass a background check.
• Must successfully pass a pre-employment drug screen and breath alcohol test (if applicable).
• Must complete an Employee Health meeting prior to starting employment.

Qualifications

Education

Preferred Bachelors or better in Nursing or related field.

Experience

Preferred 2 years: Two years of experience in acute care setting.

Licenses & Certifications

Required BLS Registered Nurse Colorado Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.

Memorial Regional Health