Mercy Medical Center Clinton RN Utilization Management Full Time Days in Mercy Medical Center - Sioux City, Iowa

Department:

SC101_65510 Utilization Management

Expected Weekly Hours:

40

Shift:

Day Shift

Position Purpose:

Job Description Details:

Position Title: RN MMC Bargaining Unit-Utilization Review

Job Code: 9000

Reports To: Manager Case Management Services

Pay Grade: Bargaining Unit RN (grid)

Dept/Clinic: Utilization Management

FLSA: Non-Exempt

OSHA: 1 - Exposure

POSITION PURPOSE:

Under general supervision, performs key case management functions to ensure continuity of care and services by collaborating and communicating with physicians, nursing supervisors, interdisciplinary team members, and all payers. Promotes the delivery of quality, effective health care while maximizing favorable utilization patterns and minimizing unfavorable expenditures through prospective, concurrent, retrospective review and quality assurance monitoring of care. Adheres to the principles of Service Excellence Guiding Behaviors and the philosophy and mission of Mercy in all aspects of job performance.

ESSENTIAL JOB FUNCTIONAL COMPETENCIES:

  • Demonstrates the knowledge and skills necessary to provide service/care appropriate to the age of the patients served, in accordance with Mercy standards.

  • Prioritizes components of an in-depth assessment to determine patients’ holistic health status on an ongoing basis.

  • Assesses the individual record of each inpatient to determine medical necessity, through concurrent review process, on assigned nursing units.

  • Facilitates and coordinates appropriate health services; using nursing process and screening criteria to assist physicians and interdisciplinary team members in determining the most appropriate level of care for the individual needs of the patient.

  • Monitors and evaluates treatment plan and outcomes for maximum utilization of resources.

  • Documents case management services in a timely manner.

  • Provides support to physicians and interdisciplinary team members in case management and discharge planning efforts.

  • Through early identification, reports potential catastrophic and high cost cases to director, nurse supervisor, and finance department for appropriate medical/administrative review and management.

  • Monitors daily utilization appropriateness including prior authorization, admission certification/recertification, concurrent and retrospective review and associated analysis, and referral appropriateness.

  • Makes determinations regarding appropriate level of care, home care appropriateness, and benefit interpretation from a clinical point of view.

  • Reviews and documents recommendations toward individualized coordinated care plans, while monitoring for possible risk, utilization, and infection concerns.

  • Prepares monthly Quality Monitoring and Utilization Management Reports as required to meet standards and regulations; as well as those needed to supplement specific service line information on the nursing units.

  • Assists in the development of CPG’s and serves as a resource in the identification of variances, and participates in the development of action plans designed to correct the unfavorable outcomes identified.

  • Provides support to physicians, patients/families, health care providers, and/or contracted groups, as indicated, to ensure quality care is being rendered in the most cost effective manner and in the most appropriate setting.

  • Facilitates the achievement of quality clinical outcomes and effectively manages length of say and cost reduction.

  • Provides education, as necessary, to ensure performance improvement.

  • Refers questionable cases and those not meeting criteria to appropriate resources, assists in coordination the evaluation and review for action, maintaining good rapport and cooperative relationships throughout the process.

  • Helps to identify problems and participates in the resolution of these; through a conflict management approach, which will result in the most constructive outcome for all parties involved.

  • Serves as a facilitator at unit discharge planning conferences.

  • Demonstrates the knowledge and skills necessary to provide services/care appropriate to the age of patient served across the continuum of care, in accordance with hospital departmental/unit standards.

  • Maintains current knowledge of rules, regulations, policies and procedures related to utilization management and continuity of care programs and criteria.

  • Actively participates in interdepartmental meetings, committees, conferences, and in-services on the nursing units and or as provided by Staff Development. Disseminates information appropriately.

  • Is knowledgeable and actively participates in improving patient safety and reducing risk to patients. Complies with Safety and Infection Control Policy & Procedure.

  • Demonstrates accountability by actively participating in unit Performance Improvement activities.

  • Recognizes lawful/ethical limitations to his/her role in the nursing process. Practices within licensure of Iowa Nursing Board.

  • Knows, understands, incorporates, and demonstrates the Mercy and Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.

  • Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Mercy and Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

  • Maintains confidentiality of information pertaining to clients, physicians, employees, and Mercy business.

  • Demonstrates general working knowledge of computers and department specific software (i.e. Healthstream, internet, etc.)

  • Performs other duties and responsibilities as assigned.

The above statements are intended to describe the general nature and level of work being performed by persons assigned to this classification. They are not to be construed as an exhaustive list of duties so assigned.

MISSION STATEMENT

We serve together in Mercy and Trinity Health, in the spirit of the Gospel, to heal body, mind and spirit, to improve the health of our communities and to steward the resources entrusted to us.

GUIDING BEHAVIORS

The Guiding Behaviors are the behaviors necessary for all of us to achieve our Vision. They are:

  • We support each other in serving our patients and communities.

  • We communicate openly, honestly, respectfully and directly.

  • We are fully present.

  • We are all accountable.

  • We trust and assume goodness in intentions.

  • We are continuous learners.

COMMITMENT

Must be able to embrace and adhere to the Guiding Behaviors of the organization and support the Mission of Trinity Health.

Must demonstrate good work habits such as time management, attendance, punctuality, team building and other behaviors aligned to the Guiding Behaviors of the organization.

MINIMUM QUALIFICATIONS

  • Is a registered nurse maintaining current licensure defined by Interstate Compact.

  • All registered nurses hired after January 1, 2014, are required to obtain a BSN degree within 4 years of hire.

  • Basic Life Support Certification (BCLS) is required unless doctor’s release is provided, in which case yearly proficiency must be demonstrated through oral and written testing.

  • Broad clinical knowledge with a minimum of three to five years experience in acute medical/surgical setting required. (Knowledge of psychiatric, chemical dependency, rehabilitation, and skilled care units preferred, but not required.)

  • Working knowledge of utilization review, coding DRG’s and computer systems preferred.

  • Excellent interpersonal, written, and verbal communication skills.

  • Is able to communicate effectively with all members of the health care team.

  • Must have a general working knowledge of computers and department specific software (i.e. Healthstream, internet, etc.)

  • Must be comfortable operating in a collaborative, shared leadership environment.

  • Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Mercy and Trinity Health.

Mercy cultivates, upholds and supports a safe work environment. Associates support patient and staff safety by demonstrating aptitude and maintaining organizational employment standards and requirements. Associate job performance is continually appraised and formally evaluated during the course of employment with Mercy.

PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS

  • Must successfully pass employment physical examination and must adhere to applicable organizational requirements on an annual basis for Employee Health Directives.

  • Must possess the ability to comply with Mercy and Trinity Health policies and procedures.

  • This job is categorized as "Light Work".

  • Has the physical stamina to meet the requirements of this job.

  • Exerting up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently.

  • Involves sitting most of the time, but may involve walking or standing.

  • Must be able to handle stress effectively.

  • Must understand and accept the possibility of exposure to environmental elements, internal and external, which may affect the work place, such as infectious disease, chemical and/or chemical fumes, dust, noise, physical injury from an out of control patient, and adverse effects of inclement weather which may occur.

These essential functions identify the major requirements of the job. They are not an exhaustive list of all job requirements. An employee may be called upon to perform physical actions not specifically identified in this job description.

Trinity Health's Commitment to Diversity and Inclusion

Trinity Health employs about 133,000 colleagues at dozens of hospitals and hundreds of health centers in 22 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Trinity Health's dedication to diversity includes a unified workforce (through training and education, recruitment, retention and development), commitment and accountability, communication, community partnerships, and supplier diversity.

Trinity Health is one of the largest multi-institutional Catholic health care delivery systems in the nation, serving diverse communities that include more than 30 million people across 22 states. Trinity Health includes 94 hospitals, as well as 109 continuing care locations that include PACE programs, senior living facilities, and home care and hospice services. Its continuing care programs provide nearly 2.5 million visits annually.

Based in Livonia, Mich., and with annual operating revenues of $17.6 billion and assets of $24.7 billion, the organization returns $1.1 billion to its communities annually in the form of charity care and other community benefit programs. Trinity Health employs about 133,000 colleagues, including 7,800 employed physicians and clinicians.

Committed to those who are poor and underserved in its communities, Trinity Health is known for its focus on the country's aging population. As a single, unified ministry, the organization is the innovator of Senior Emergency Departments, the largest not-for-profit provider of home health care services — ranked by number of visits — in the nation, as well as the nation’s leading provider of PACE (Program of All Inclusive Care for the Elderly) based on the number of available programs. For more information, visit www.trinity-health.org at http://www.trinity-health.org/ . You can also follow @TrinityHealthMI on Twitter.