Case Manager/Utilization Review RN

Navajo Preference Employment Act

In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act.  Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference.
Overview

POSITION SUMMARY

Incumbent serves as an Outpatient/Inpatient Case Manager/Utilization Review Registered Nurse (CM/UR RN) for TCRHCC and is responsible for direct supervision and supportive contact for the specific group of identified patient assignments and high-risk patients.  The CM/UR RN is responsible for designing and managing a continuum of care focusing on empowering clients to achieve demonstrable outcomes and self-sufficiency.  The CM/UR RN is responsible for assessment, service planning, and resource acquisition, monitoring progress and initiating and responding to emerging client needs.  The CM/UR RN performs Utilization Review and Management/Clinical Documentation Chart Reviews of patients in the acute clinical care setting, ambulatory care setting and will conduct UR reviews as required. The CM/UR RN will work closely with the Social Work (MSW) Case Manager on Discharge Planning and Care Transitions. The CM/UR RN will work closely with the Physician Advisor and participate on the UR Committee as well as conduct Clinical Documentation Chart Reviews related to peer review, financial or insurance determination, or claims denials. The CM/UR RN will link the client with Community Social Service providers, health care providers, substance abuse, and mental health providers to achieve specific goals.  The CM/UR RN will have experience working with culturally diverse low-income populations having multiple barriers to self-sufficiency such as: illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues.  The CM/UR RN will work with a multidisciplinary team within the service delivery setting.  The CM/UR RN will be committed to Case Management Services and have some collaboration with Purchased and Referred Care (PRC) formally known as Contract Health Services, providing assistance with the PRC Case Specialist.  The CM/UR RN reports to the Director of Care Coordination.

The CM/UR is responsible for compliance with CMS Conditions of Participation regarding Utilization Review and Discharge Planning including implementation and annual review of the Utilization Management Plan and assisting with the coordination of the Utilization Management Committee. The CM/UR is also responsible for ensuring compliance with the Joint Commission and Federal and state regulatory bodies, provisions of care regarding discharge planning and patient needs for care, treatment, and services after discharge or transfer are met. The CM/UR follows the hospital's Case Management/Utilization Program that integrates the functions of utilization review, discharge planning, and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated resources. The hospital’s case management model outlines a collaborative practice to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes.

Qualifications

NECESSARY QUALIFICATIONS

Education:

Associates Degree in Nursing, must obtain bachelor’s in nursing within two (2) years of hire

       License/Certification:

• A valid, current, full and unrestricted Professional Nursing License to practice as a Registered Nurse (RN) in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
• Must have and maintain current Basic Life Support (BLS) certification by the American Heart Association (AHA) throughout employment

Experience:

• Three (3) years of clinical nursing experience performing direct patient care with at least 2 years in an Inpatient setting on a medical-surgical unit, PACU, or higher acuity Inpatient unit (ICU, Step-Down, Telemetry, etc.) or home health (direct care) {clinical experience qualification may be determined by hiring manager/director.}
• Demonstrate knowledge of the case management, purchased referred care and utilization review
• Demonstrate knowledge of electronic health record systems

Other Skills and Abilities:

A record of satisfactory performance in all prior and current employment as evidenced by positive employment references from previous and current employers.  All employment references must address and indicate success in each one of the following areas:

• Positive working relationships with others
• Possession of high ethical standards and no history of complaints
• Reliable and dependable; reports to work as scheduled without excessive absences
• Effective verbal & written communication skills
• Team management focus promoting a positive and pro-active approach to problem resolution
• Completion of and receiving above-satisfactory scores on all job interviews, demonstrating to the satisfaction of the interviewers and TCRHCC that the applicant can perform the essential functions of the job 
• Successful completion of and positive results from all background and reference checks, including positive employment references from authorized representatives of past and current employers demonstrating to the satisfaction of TCRHCC a record of satisfactory performance and that the applicant can perform the essential functions of the job
• Successful completion of fingerprint clearance requirements, physical examinations, and other screenings indicating that the applicant is qualified to be employed by TCRHCC and demonstrating to the satisfaction of TCRHCC that the applicant can perform the essential functions of the job
• Submission of all required employment-related documents, applications, resumes, references, and other required information free of false, misleading or incomplete information, as determined by TCRHCC.

MENTAL AND PHYSICAL EFFORT

The physical and mental demands described here are representative of those that must be met by an   employee to successfully perform the essential functions of this job.  Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Physical:

This position requires an individual of high energy who can maintain a long and flexible schedule to meet the management requirements. The physical requirements include; sitting at a desk for long periods of time, long periods of sitting in meetings; frequent sitting for intense work on a personal computer, frequent walking to interact with staff within the facility, frequent bending, kneeling, crouching, twisting, maintaining balance and reaching. Must be able to hear, speak and comprehend over the telephone and in person with others. Must have ability to lift, push and pull up to 50lbs frequently. Sensory requirements for position include prolonged ability for far, near, and color vision, depth perception, seeing fine details, hearing normal speech, telephone use and ability to frequently hear overhead pages. Must have ability of both hand manipulation in simple and firm grasping, fine manipulation, and use of keyboard.

Mental:

Uses independent judgment and analytical skills to make decisions that impact operations, finances, and customer service within the organization.  The incumbent must have the ability to perform in structured and unstructured environments and possess a keen attention to detail and propose practices/mechanisms to enhance customer satisfaction. Must have ability to continually concentrate, handle a high degree of flexibility, handle multiple priorities in stressful situation, demonstrate high degree of patience, adapt to shift work, work in areas that are close in crowded, frequently cope with high levels of stress, make decisions under high pressure, work alone, and occasionally cope with anger/fear/hostility of others in a calm way and manage altercations.

Environmental:

May frequently be exposed to chemical agents, extremes in temperature of humidity, occasional exposure to infectious diseases, dust, fumes, gases, hazardous or moving equipment, and loud noises.

Responsibilities

ESSENTIAL FUNCTIONS

1. Adheres to most current ACMA Case Management Standards of Practice and Scope of Services
2. Adheres to ANA Nursing Scope and Standards of Practice
3. Adheres to most current ANA The Code of Ethics for Nurses
4. Coordination of service specific assessments, service planning and enrollment.
5. Works with all facets of the Case Management continuum, i.e., social support, alternate resources, community referrals, discharge planning, Nursing Home/Skilled Nursing Placement and resource utilization.
6. Comprehensive and client centered service planning and coordination
7. Works proactively with the established RN Case Managers/ Social Workers of TCRHCC as a team member for care coordination of the patient populations served by TCRHCC.
8. Resource acquisition facilitated referrals and linkages.
9. Consistent and on-going case consultation with all direct service providers.
10. Developing and maintaining internal and external resource relationship.
11. Service monitoring and following up to ensure continuity of care and updating of the client service plan
12. Identifies patient through consultation and high-risk diagnoses, i.e. COPD, CHF, DM
13. Assists with the development of department reports, policy/procedures manuals, and program objectives
14. Assists with special projects and reports as assigned.
15. Conducts system and procedural efficiency evaluation to determine progress, performance, and conformity with program requirements.
16. Follow up outside inpatient case management referrals for continued follow up, I.E., appointments and PHN referrals. Will provide case management coverage for the inpatient units and case management referral follow up for the outpatient clinics. Will prioritize TCRHCC/SPHC outpatient/inpatient case management based upon referrals from providers within the TCRHCC/SPHC healthcare delivery system and high-risk assessment conducted on inpatient population. Will provide a consistent and on-going collaboration through communication with service providers.  Facilitates appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record. 
17. Improves the overall quality and completeness of clinical documentation by performing admission/continued stay clinical reviews using clinical documentation enhancement guidelines for selected patient populations.
18. Reviews clinical issues as needed with the coding staff to assign a working DRG to reflect any changes in patient status and procedures/treatments and confers with the physician to finalize diagnoses.
19. Conducts timely follow-up reviews of clinical documentation to ensure that issues discussed and clarified with the physician have been recorded in the patient’s chart.
20. Participates in review and analysis of monthly data relating to clinical quality documentation and insurance medical necessity criteria.
21. The incumbent will perform UR coordination functions by ensuring medical necessity of preadmission, admission, continued stay, cost containment and discharge planning on patients admitted TCRHCC.