Assess and analyze the patient’s record according to pre-established criteria for severity of illness and intensity of services provided. Compare data from the patient record to criteria and collaborate with the healthcare team to assure appropriate utilization of services. Serve as consultant to the provider, assuring proper placement within the continuum of care.
Complete reviews accurately and timely, using Interqual criteria. Monitor observation stays, assure admission to inpatient as soon as inpatient criteria has been met, or ensure discharge from observation status as soon as possible. Screen for Medical Staff quality issues using criteria set by Medical Staff.
Reviews insurance verification information in Electronic Medical Record (EMR) and determines what medical information is required for certification of stay/services. Takes action based on insurance companies' requirements to ensure that appropriate information is submitted and time frames are met for certification and to comply with reimbursement standards. Works with supervisor to obtain certification from insurance companies for patient stays.
This involves obtaining clinical information from CERME and faxing required information to insurance companies. Obtains insurance information and approvals for discharges. This would include contacting insurance companies for information needed to facilitate discharge.
Assess the health status of assigned patients by collecting and analyzing patient data and evaluate appropriateness of nursing, medical and ancillary care. Evaluate potential for safe discharge to home, identifying limitations and need for referral services. Thoroughly and accurately document the discharge plan ensuring regulatory compliance.
Tracks faxes sent to insurance companies to ensure certification information is received. Reviews the EMR when further information is needed by insurance companies and follows up to make sure that information is submitted in a timely fashion. Tracks patients that are discharged and faxes discharge information when appropriate.
Obtains and tracks certification on patients that have been discharged. Assess and evaluate overall patient plan of care/care pathways in collaboration with attending provider and team members and intervene as appropriate on a concurrent basis to resolve potential patient-specific avoidable days. Coordinate services for complex cases and provide discharge options and referrals to community resources to those in need.
Ensure collaborative planning processes are maximized and informed decisions are made in conjunction with the patient, family, and healthcare team throughout the continuum of care. Consult with care team to address barriers, identify sources of duplication and service fragmentation and facilitate process changes to achieve desired outcomes to the patient’s progress. Notify Social Services for ongoing inpatient/observation patient issues.
Arrange interdisciplinary care conferences in collaboration with other team members. Tracks and assists staff to obtain signatures on needed forms to facilitate discharge (i.e. Choicelists, Important Message from Medicare, etc.).
In collaboration with health team, facilitate the development of appropriate educational material, instruction to patients, families, nursing personnel, medical staff, and multidisciplinary personnel to accomplish desired outcomes. Maintain knowledge of discharge agencies/resources available to meet the patient’s needs. Monitor use of resources such as time, people, and products to achieve patient outcomes and decrease length of stay.
Counsel patients/families on “Prudent Lay Person” list from Medicaid and appropriate utilization of Emergency Services. Counsel patients/families on financial options available for payment of medical services (i.e., referral to Claim Aid). Serve as liaison with third party payer to obtain authorization/certification for the hospitalization.
Participates with and assists nursing staff in performance improvement initiatives as identified by the department, Utilization Review Committee, or other JMH-directed activities. Prepare, present, and communicate data and findings from the performance improvement initiatives to nursing staff, provider, administration, and other disciplines involved in providing care. Work appropriately with persons of varied ages, racial, ethnic, and sociological backgrounds.
Performs additional related duties as assigned. Clearly communicates and continuously supports the Mission and Values of Johnson Memorial Health. Conducts all activities in compliance with applicable laws, regulations, standards, and hospital policies and procedures including Blood and Body Substance Precautions.
EDUCATION, EXPERIENCE AND TRAINING: BSN required. Current Indiana RN licensure in good standing required. One year experience in behavioral health is required.
One year experience in case review in a hospital acute care setting is preferred. Clinical pathway experience and certification in Case Management preferred. Must be familiar with managed care, Medicare, and Medicaid guidelines, along with precertification, concurrent and retrospective review.
Experience with HFAP/ACHC accreditation preferred. Johnson Memorial Health is a nationally-recognized network of physicians, services and healthcare resources based in Johnson County, Indiana. The centerpiece is Johnson Memorial Hospital, located in Franklin Indiana, just 20 minutes south of Indianapolis.
All qualified applicants will receive consideration for employment without regard to race, age, sex, color, religion, sexual orientation, gender identity, national origin, protected veteran status, disability, or other protected characteristic under applicable law.
Monday - Friday, 8:00 a.m. - 4:00 p.m. 75 hours per biweekly pay period.