Coordinates systems and services with an organized, transdisciplinary team approach which delivers quality, cost-efficient care to patients through the continuum of health care services. Appropriateness of admission and continued stay reviews are conducted concurrently or retrospectively. Collaborates with the patient, family and other members of the health care delivery team to facilitate appropriate movement through the care continuum as demonstrated through quality outcomes. Works effectively with internal and external customers and proactively improves case management processes. Provides direct input to St. Anthony Hospital annual Utilization Management/Case Management/Performance Improvement Plans and is accountable for the successful completion of the action plan developed.
Comply with national and state compliance standards. Assess data to determine medical necessity and appropriateness of level of care and/or admission based on approved criteria, with minimal direction. Attend and actively participate in departmental, hospital and medical staff meetings as assigned.
Monitor utilization of resources and services in a quality-conscious manner and in relation to covered services and length-of-stay parameters. Manage clinical and operational bottlenecks which impact the quality, length of stay and resource utilization and documents the results. Negotiate the utilization and coverage of services with other stakeholders.
Refer all questionable utilization cases to the physician advisor and/or management for discussion and facilitates action plans developed. Prioritize caseload according to changes in the patient's condition, the current and future care plans. Coordinate denial of benefits notice with physician, business office and patient/family.
Assist patients in benefits management to include proactive negotiation with third-party payors and agencies to optimize payment of services rendered for alternative cost-effective levels of care to activate client needs and interests. Assume a global perspective with regard to the fiscal well-being of the patient, the organization, network and the health care system.
Promote safe, competent utilization review and discharge planning using philosophy, policies, procedures and standards of care of various disciplines to in include, department, and national standards. This is accomplished through rounds, multi-disciplinary team conferences and meetings with patients/families, payors and health care team members the patient's needs, including needs related to age, medical diagnosis, treatment options, financial resources, psycho-social and spiritual needs, knowledge base, health status expectations and discharge planning. Collaborate with the patient/family and multidisciplinary staff to develop and adjust care protocols, treatment goals, and discharge goals. Coordinate care and establishes goals for a specific patient population from pre- admission through discharge. Consult with Social Worker, BS to facilitate difficult discharges, nursing home discharges, and other social issues.
Collect, record and maintain clinical information gathered from concurrent or retrospective review of the medical record and compares to approved standards, pathways or protocols. And input into on line InterQual (CERMe).
Participate actively in the collection and analysis of outcome data, e.g., quality, length-of-stay, cost and charge, and identify and make recommendations for improvement within a designated patient population or service line.
Serve as a resource and hospital liaison to patients/families, physicians, the health care team and external organizations with regard to the case management program, available health care resources, appropriate level of care and financial issues. Contribute to the development, monitoring and evaluation of the department performance improvement plans.
Demonstrate respect for self and always respects the rights and dignity of others. Recognize patient rights by providing for confidentiality of patient information and by reporting ethical issues through appropriate processes. Accountable for own learning needs and seeks opportunities to increase competencies and to receive feedback.
Function as a liaison for patients and families for their payor pan, knowledgeable about Medicare and Medicaid regulations. Educate nursing staff and physicians about case management programs.
Perform other related duties as assigned that correspond to the overall function of this position.
Licensed by the Oklahoma Board of Nursing as a Registered Nurse.
Three years of recent clinical experience in health care as a registered nurse with demonstrated management experience and leadership ability.
Current CPR (Healthcare Provider).
Two years Utilization Review/Utilization Management or Case Management preferred.
Knowledge of computer software and hardware applications and basic statistics preferred.
St. Anthony Hospital –
St. Anthony Hospital is a 601-bed regional referral facility specializing in cardiology, oncology, surgery and behavioral medicine. The hospital, established in 1898, is located in Midtown Oklahoma City and serves the needs of Central Oklahoma, as well as many counties throughout Oklahoma, through its large rural affiliate network of hospitals. Four St. Anthony Healthplex campuses provide convenient emergency and outpatient service access to the outlying communities of the metropolitan area. St. Anthony added urgent care services in May 2015 at St. Anthony North. St. Anthony has received numerous awards including the Oklahoma Quality Award for Excellence, Certified Healthy Business, Premier QUEST® Award for High-value Healthcare Citation of Merit, among others. Healthsights ranks St. Anthony at performance levels for quality and patient satisfaction higher than local competitors and many national health care organizations.
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