Analyzes patient medical records concurrently and/or retrospectively for quality assessment and discharge planning criteria. Provides supportive documentation and clinical records to insurance carriers for authorization of services. Coordinates discharge plans and orders for patients leaving the hospital including identifying needs for community services and making appropriate transition plans. This position requires creativity and problem solving, multi-tasking, and the ability to prioritize tasks and work with minimal supervision.
Performed majority of the time -- please start with the responsibilities that are the most time consuming:
· Applies and shares knowledge of community health and social service resources.
· Evaluates medical information and completes discharge needs assessments within 1 day of admission as set by established criteria, to identify patients that are at high risk of requiring post-hospital services, and the need for case management and discharge planning intervention.
· Initiate and complete safe discharge plans for inpatients by arranging Home Health referrals, complex drug therapy interventions, outpatient clinic visits, skilled nursing placements, intermediate care placements, assisted living arrangements, etc.
· Documents initial assessment of the patient and continually assesses discharge needs through the continuum of care.
· Works closely with external vendor partners to arrange post-discharge needs, maintains amiable and professional relationship with vendors at all times.
· Assesses variables that impact health and functioning, interprets clinical information and assesses implications for treatment.
· Issues Important Messages from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), and denial of services letter following appropriate health plan or Medicare guidelines.
· Collaborates with Hospitalists and Multi-Disciplinary team daily to facilitate the timely discharge of patients from the hospital setting.
· Enters Avoidable Days and Code 44 Documentation when appropriate.
· Provides information to patients and families on “Advanced Directives” when requested.
· Responds to outpatient and community questions and referrals.
· Screens patient’s medical records concurrently and/or retrospectively using pre-established screening criteria for quality assurance and discharge planning.
· Facilitates discharge planning for the continuum of care.
· Facilitates placements or referrals as appropriate to meet the patient’s clinical needs/rights and are specific for neonate, infant, pediatric, adolescent, adult and geriatric populations.
· Reports suspected abuse, neglect, or unsafe discharge environment to the appropriate agency.
· Develops an individualized case management plan that addresses physical, vocational, psychosocial, age, cultural, financial and educational needs and documents case management activities.
· Coordinates the appropriate services and resources needed.
· Communicates with patient/family/significant others and all multi-disciplinary team members for appropriate post-hospital services/needs.
· Consults with the social worker to identify appropriate social service needs.
· Provides insurance carriers with necessary information to authorize follow-up care when necessary and obtains pre-authorization for post-discharge services including Skilled Nursing, Durable Medical Equipment, Home Oxygen, or Rehabilitation.
· Relays pertinent information to the Case Management Manager to represent Case Management with internal medical or quality committees, inpatient nursing staff, ancillary provider staff as appropriate.
Performed occasionally but critical to successful performance of the job:
· Attends scheduled staff, care conferences, and other meetings as appropriate
· Attends Utilization Review Committee meetings as schedule allows.
· Shares information from seminars and other sources of education with others as appropriate.
Decision making and budget responsibilities (e.g. impact limited to the employee, entire unit or organization-wide):
· Impact limited to the employee.
· Bachelor or Master of Science in Nursing. **Current RN employees as of 1/27/2020 will be grandfathered back to the previous education requirement at their time of original hire. **
· 2 years’ experience practicing as an RN
· Strong clinical nursing skills with five (5) years hospital experience in varied clinical settings.
· Knowledge of insurance carriers and Medicare guidelines in the hospital environment.
· Knowledge of community health and social service resources.
Licenses, Certifications and/or Registrations:
· Current license as a Registered Nurse by the Oregon State Board of Nursing.
· American Heart Association Healthcare Provider BLS.
· Certification in Case Management from ACMA Or CMSA.
· Certified Medical Translator
Job Related Skills, Abilities and Behaviors:
· Demonstrates ethical commitment to quality assurance and confidentiality of all data and information.
· Emulates dress code and Code of Conduct that incorporates presenting a good first and lasting impression by personal appearance and interpersonal skills.
· Advanced communication and interpersonal skills that utilizes consideration body language, filters, listening, paraphrasing, and questions with customers of diverse ethnic and cultural backgrounds. This also includes the skills to obtain and interpret information appropriate to patients' needs and age as required for assessment, range of treatment and patient care.
· Ability to write clear and legible clinical notes.
· Experience working in highly confidential settings.
· Possesses excellent telephone skills and interpersonal communication abilities both verbal and written.
· Ability to develop case management care plans and solutions utilizing critical thinking and problem-solving skills.
· Familiar with computerized word processing and electronic medical records.
· Ability to implement ideas and programs required.
· Self-directed and must be able to follow through on projects with attention to detail and implement ideas and programs with minimal supervision.
· Demands creativity, flexibility and the ability to work under stress.
· Applies problem-solving techniques to the case management process.
· Maintains familiarity with disease processes, available resources and treatment modalities, assessing their quality and appropriateness for specific disabilities, illnesses and injuries.
· Provides care appropriate to the age of patients served pediatric, adolescent, adult, and geriatric patients based on principles of growth and development and life stages.
· Demonstrates confidentiality according to PHI regarding patient and co-worker information.
· Demonstrates an understanding of insurance policy language and various health care options.
· Responds to correspondence independently, as appropriate.
· Exhibits the ability to learn "just in time" and shares findings with others.
· Demonstrates ability to work in a team situation.
· Ability to facilitate family care conferences, manage multiple interruptions, communicate effectively with patients and act as patient advocate.
· Advocates and respects patients’ rights and/or significant other’s rights.
· Utilizes problem-solving techniques consistently to resolve complaints or concerns.
· Maintains a cooperative and harmonious relationship with staff and management.
· Demonstrates respect of others, communicates clearly and attempts to resolve interpersonal conflicts.
· Develops and maintain collegial relationships with other professionals by attending continuing education and professional group sessions.
· Bilingual skills a plus.
At OHSU Tuality Healthcare, an OHSU Health partner, it's an honor and a privilege to serve those near us. That's why since our beginnings in 1918, and as we expand our strong network of services through our clinical affiliation with OHSU Health, we continue to be committed to providing the best health care possible and a valued community partner. Our affiliation with OHSU Health brings the advanced medical resources of Oregon’s only academic health center, which allows local providers to receive guidance from some of the country’s top specialists and pass that expertise on to our patients where they can be cared for in their community.
OHSU Tuality’s many awards showcase our position as one of the Portland metro area’s premier healthcare providers, including our 7th straight year in Top 10 Healthiest Employers in Oregon from The Portland Business Journal, and our 7th straight Gold Plus Award from the American Heart Association.