RN II-Case Management/ Utilization Review (CNA) at Adventist Health

San Luis Obispo, California, United States -

Full Time

Start Date

Immediate

Expiry Date

05 Jun, 26

Salary

0.0

Posted On

07 Mar, 26

Experience

2 year(s) or above

Remote Job

Yes

Telecommute

Yes

Sponsor Visa

Skills

Case Management, Utilization Review, InterQual Criteria, Discharge Planning, Acute Care Hospital Setting, RN License, Basic Life Support, Payer Guidelines, Advance Directive, Team Conferences, Medicare Conditions Of Participation, Word, Excel, Outlook, Internet Navigation

Industry

Hospitals and Health Care

Description

Nestled on the Central California Coast, Adventist Health Sierra Vista has been providing care to our community since 1959. Our 162-bed acute care facility includes a Level III Neonatal Intensive Care Unit and county designated trauma center. San Luis Obispo offers the excitement of a lively community while being a fifteen-minute drive from the serenity of Avila Beach, known for their natural hot springs, and Pismo Beach, known for their sand dunes and eucalyptus trees. Featuring a charming downtown, comfortable coastal weather, idyllic views, and an active lifestyle San Luis Obispo offers much to be had. Job Summary: Assesses appropriateness of admission status and level of care, using InterQual criteria. Provides discharge planning services, coordinating with patients, families, and community agencies. Collaborates with medical staff in assuring appropriate utilization of hospital resources and expediting high quality patient care. Ten hour shifts with an occasional weekend in rotation. Knowledge of InterQual criteria and Medicare Conditions of Participation preferred. Basic computer skills, including Word, Excel, Outlook, and navigating the Internet are necessary. This position is represented by CNA. Job Requirements: Education and Work Experience: * Associate Degree(A.S.) or equivalent: Required * Bachelor's Degree in Nursing: Preferred * Three-Five years nursing experience in an acute care hospital setting: Required * Recent experience in utilization review, discharge planning, and/or inpatient case management: Preferred Licenses/Certifications: * Current RN license in state of practice: Required * Basic Life Support (BLS OR HS-BLS OR RQIBLS) certification: Required * Registered Nurse (RN) license in state of practice: Required Essential Functions: * Continuum of care: A) Assists MD in making admission decision regarding observation or inpatient status and payer guidelines. B) Reviews patient chart on day of admission or first day after admission for SI/IS. C) Completes Advance Directive form as needed. D) Identifies need for follow-up case management and documents opportunities for intervention based on chart review, multi-disciplinary referrals or MD orders. E) Coordinates team or family conferences to ensure timely responses to needs. F) Pro-actively assists in development of patient care and teaching plan. G) Completes InterQual reviews and reveiws care and progress on assigned patients as often as necessary but no less than every 72 hours and documents progress in the computer system and patient chart. H) Moves patients through the system based on level of need and is responsive to any need which interferes with the plan of care. I) Issues HABN letters as needed. J) Refers cases that do not meet InterQual criteria to the UR advisor. * Utilization Management: A) Obtains optimal coverage for patients by furnishing appropriate medical information to insurance carriers and governmental agencies. Utilization Management: B) Serves as liaison between payers, MD, patients, families and financial counselor. * Utilization Management: C) Collaborates with appropriate team members to maximize re-imbursement through essential documentation. Utilization Management: D) Documents authorizations/denials in computer system when received. Utilization Management: E) Is proactive in discussions with MD regarding appropriate inpatient testing * Discharge Planning: A) Anticipates discharge needs and makes appropriate suggestions for referrals linking the patient and family to resources within and outside the health care delivery system and/or community. Discharge Planning: B) Ensures patient is medically stable for discharge and patient and family is prepared educationally, emotionally and functionally for discharge. Discharge Planning: C) Coordinates transfer of patients to other facilities in a timely manner. * Documentation: Provides accurate documentation in patient record and hospital computer system to reflect CM needs, goals and planned interventions. * Performs other job-related duties as assigned. Organizational Requirements: Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply. Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.

Responsibilities

The RN II Case Manager assesses admission status and level of care using InterQual criteria, provides discharge planning, and collaborates with medical staff to ensure appropriate utilization of hospital resources and high-quality patient care delivery. Responsibilities include coordinating care transitions, issuing necessary letters like HABN, and managing authorizations/denials from payers.