Responsible for assessing and monitoring appropriate safe discharge plan by promoting quality, cost effective options, and interventions for patients in an acute care setting and as the patient transitions through the continuum of care. Through a collaborative process, participates in interdisciplinary patient rounds in assigned patient care unit with ability to lead discussion and direct plan.
Ensures medical appropriateness criteria are met for level of care provided and is documented from admission through discharge. Reevaluates plan of care and ensures continued appropriateness based on the patients changing needs and condition as well as to identify potential delays, determine effectiveness and patient/family satisfaction. Maintains working knowledge of specialized case and utilization management methodologies and practices; applies concepts to everyday practice.
Provides decision support for the treatment care team regarding documentation elements required by regulatory agencies and payers, e.g., Medicare, Medi-Cal, Health Plans, and Contracts; helps team understand the interrelationship of reimbursement with efficient and appropriate utilization of resources and service. Maintains working knowledge of specialized case and utilization management methodologies and practices; applies concepts to every-day practice. Completes required continuous training and education, including department specific requirements to maintain current knowledge of department and hospital policies, procedures and billing practices, compliance plans, federal and state regulations , insurance regulations and accrediting body standards concerning the case and utilization management. Understands and adheres to the California Nurse Practice Act, The American Nurses Association (ANA) Code of Ethics for Nurses, the ANA Bill of Rights for Registered Nurses and the ANA Scope and Standards of Practice for Nursing.
Speak and read English at a level that is sufficient to satisfactorily perform the essential functions of the position. Knowledge of standard office equipment (i.e., calculator, fax, photocopier) and personal computer and computer software skills (i.e., MS Windows, Excel, Access, Word, Powerpoint, internet, e-mail). Windows computer skills including proficient use of keyboarding, use of mouse or keys for functions such as selecting items, use of drop down menus, scroll bars, opening folders, copying and similar operations required upon employment or within the 1st two weeks of employment to perform the essential functions of the job.
Performs other duties as assigned. Follows Palomar Health rules, policies, procedures, applicable laws and standards. Carries out the mission, vision, and quality commitment of Palomar Health.
Minimum Education: As required by certification and/or licensure
Preferred Education: Bachelor's Degree and/or National Certification in Utilization Review or Case ManagementMinimum Experience: 1 - 3 years of directly related RN experience
Preferred Experience: 3 - 5 years acute care nursing experience
Completion of Utilization Review/Case Management course
Required Certification: American Heart Association recognized BLS - Healthcare ProviderPreferred Certification:
Not ApplicableRequired License: Current CA RN LicensePreferred License: Not Applicable