UTILIZATION REVIEW/CASE MGMT/BEST PRACTICE REGISTERED NURSE (PCN227)
Work Hours: Days
The Utilization Review / Case Management / Best Practice RN (UR/CM/BP RN) position is established to assist with ensuring the placement and provision of cost-effective, best-practice, health care services. S/he will be accountable for examining and evaluating the appropriateness of the utilization of the Hospital and Long Term Care’s levels of care and resources. S/he will perform concurrent review and retrospective in-depth analysis of patient records for purposes of best practice (core measure performance). Interacts with physicians, nursing, and ancillary staff to promote accurate documentation. S/he will use various methods to manage these goals, including written and oral communications, committees, and councils, while working closely with staff in the Health Information Management, Patient Financial Services and Quality/Risk Departments as well as physicians, nurses, social services, auxiliary staff and South Peninsula Hospital (SPH) Senior Management Team.
NATURE AND SCOPE:
This is a confidential, non-exempt position. Will report to the Director of QI and works with the CFO and Director of Patient Care Services, respectively. The UR/CM/BP RN assists the CEO, Quality Director, Medical Staff, and Allied Practitioners to meet their obligations to the Board of Directors to provide high-quality, cost-effective health care. S/he will coordinate regularly held UR Meetings with these leaders and an appointed Physician liaison to review Hospital/LTC’s performance, processes, patient placement issues, payment updates, and regulatory standards. Additionally, s/he will report best practice statistics at the quarterly QI Meetings and monthly for the BOD Quality Scorecard.
KNOWLEDGE, SKILLS AND EXPERIENCE: The position of UR/CM/BP RN requires that s/he possess the minimum of a degree in nursing, BSN preferred, and a current license to practice as a registered nurse in the state of Alaska. A minimum of 3+ years of experience in an acute care hospital setting with 2-3 years of utilization management; one year best practice experience preferred. Must be certified in Basic Life Saving through the American Heart Association.
The UR/CM/BP RN must have a thorough knowledge of Utilization/Case Management/Best Practice, including, but not limited to: knowledge of regulatory standards and procedures relative to utilization and case management issues including the DRG-based reimbursement system; a thorough knowledge of third party reimbursement and methods of payment by insurance carriers; a basic knowledge of ICD-9/10 coding; and basic knowledge of the functions of all hospital departments; up-to-date knowledge of best practice core measure standards; QualityNet reporting standards and practices.
Effective speaking, listening, presenting, and writing skills are required to communicate with the medical staff and with personnel at all levels. Have effective skills in the organization and prioritization of work. Demonstrate flexibility and the ability to change; exercise good judgment and able to cope with stressful situations; positive attitude and team player. At the same time, must be able to function independently and be thorough, accurate and objective in generation of reports. Ability in business math and basic statistical analysis is required for data completion, dashboards analyses and presentation of conclusions with UR Team input/support. S/he must be computer literate and able to use word processing, spread sheets, data bases and presentation software; CPSI software program knowledge and experience preferred. Able to maintain a high degree of confidentiality is mandatory. Passion for quality, learning, analysis and teaching.
South Peninsula Hospital is a 22 bed Critical Access Hospital and 28 bed Long Term Care, located at the southern end of the Kenai Peninsula. South Peninsula Hospital has an active Medical Staff of 25 members, including five surgeons, and a large consulting staff. The working environment is generally pleasant, clean and well-maintained.