Title: RN - Utilization Review/Care Management Coordinator– Goldendale, WA
# of Positions: 1
Schedule: Full time-32 Hours per week
***This position is expected to be 32 hours per week for approximately one year, and then move to 40 hours per week and will be given the additional duties of overseeing the KVH swing bed program.
The Utilization Review/Discharge Planning Coordinator is responsible for utilization review and discharge planning of all acute care and swing bed patients. The Coordinator is familiar with the rules and regulations that govern Washington State Critical Access Hospitals, ensures that patients’ needs are met, and KVH policies and procedures are followed. Works collaboratively with nursing to screen all patients for admission, ensuring continued eligibility and appropriate discharge planning. Possesses knowledge of and utilizes community, state and federal resources. This position is responsible to work closely with ED providers and hospitalists to ensure accurate admission status based upon MCG criteria, assess all patients on the acute care unit for discharge planning needs/barriers. This position collaborates with the patient/family and members of the healthcare team to ensure a safe and effective transition through the continuum of care: arrangement of post-acute care/transitional care needs to include DME, home health, SNF or LTAC placement. Interacts with payer sources to obtain authorization. This position also requires the coordinator will conduct concurrent review, insurance authorization, insurance appeals for all acute care and swing bed/transitional care patients. The coordinator demonstrates excellence in customer service during interactions with employees, managers, supervisors, physicians, patients, patient family members, vendors, etc.
Additional Responsibilities: ( After approx. 1 year)
- Responsible for Swing Bed Program development.
- Ensures that all state and federal laws and regulations are met for the CAH swing bed designation.
- Ensures proper Swing Bed Program state survey readiness for all Acute Care staff in collaboration with the Acute Care Manager and CNO.
- Ensures a variety of activities are planned for the swing bed patients in order to give them opportunities to use and maintain their physical and mental abilities, provide outlets for social interaction, etc. This is done in collaboration with the Occupational Therapist, Volunteer Services, Acute Care Manager and CNO.
- Evaluates overall plan of care for swing bed patients, monitors patient progress and identifies any changes in status.
- Leads and documents swing bed team meetings for swing bed patients.
- Meets with patients and family members or designee throughout swing bed stay to ensure effective discharge planning and discharge preparedness.
- Establish and maintain policy, procedure and processes as they relate to the Swing Bed Program.
KVH is a Critical Access Hospital
“Critical Access Hospital” is a designation given to certain rural hospitals by the Centers for Medicare and Medicaid Services (CMS). This designation was created by Congress in the 1997 Balanced Budget Act in response to a string of hospital closures in the 1980s and early 1990s.
The CAH designation is designed to reduce the financial vulnerability of rural hospitals and improve access to healthcare by keeping essential services in rural communities. This is accomplished through cost-based Medicare reimbursement
To ensure that CAHs deliver services to improve access to rural areas that need it most, restrictions exist concerning what types of hospitals are eligible for the CAH designation. The primary eligibility requirements for CAHs are:
A CAH must have 25 or fewer acute care inpatient beds.
It must be located more than 35 miles from another hospital
It must maintain an annual average length of stay of 96 hours or less for acute care patients.
It must provide 24/7 emergency care services.
- Must be a graduate of an accredited school of nursing with an active- BSN preferred.
Minimum Work Experience
- At least three (3) years acute care nursing experience with a thorough understanding of the discharge planning process preferred.
- Previous discharge planning, utilization review, long term care/swing bed experience preferred
- Active RN or LPN license in Washington State
- Requires critical thinking skills, ability to make good decisions, listen and accept advice from others, demonstrate maturity and good judgement and the ability to work with minimal supervision.
- Communicate effectively with patients, physicians, visitors, insurance companies and providers.
- Work productively, cohesively within a team and resolve conflict/differences in a positive manner.
- Promote/develop/deliver excellent customer service to both internal (patients, physicians and staff) and external customers (visitors and vendors).
- Maintain a calm and composed manner in stressful situations, taking appropriate action as necessary.
- Demonstrate attention to detail and high degree of accuracy, risk of error could result in significant financial loss.
- Ability to monitor and consistently meet deadlines.
- Time management and organizational skills.
- Complies with mandatory, regulatory and credentialing requirements.
- Experience with using everyday computer electronic technology tools (e.g., email, data retrieval, voicemail, and internet/intranet).
- Proficiency with Microsoft Excel and Microsoft Word.
- Supports the mission, vision and values of the organization.
- Performs daily concurrent reviews of patients admitted to the acute care unit.
- Assists provider in determining admission/stay-type status of patient according to established criteria.
- Assists provider in determining other options for care when observation, inpatient, or swing bed criteria is no longer met.
- Provides care management/discharge planning services in collaboration with providers, nursing staff, and other Klickitat Valley Health district departments as indicated.
- Coordinates with community agencies and outside referral sources to ensure patient discharge planning needs are addressed.
- Maintains admission and continued stay review criteria.
- Liaison with payer’s concerning patient reviews.
- Coordinates correspondence of observation, inpatient, and swing bed appeals for insurance companies.
- Coordinates with Director of Risk & Quality to ensure adherence to utilization review, discharge planning and swing bed standards.
- Participates on the Utilization Review committee and coordinates committee meetings.
- Collaborates, and coordinates with Swing Bed Multidisciplinary Care Team.
- Identifies and addresses psychosocial, cultural, ethnic, and religious/spiritual needs of patients and their families.
- Meets with patients and family members or designee throughout stay to ensure effective discharge planning and discharge preparedness.
- Prepares and presents reports to the Board of Commissioners when requested.
- Establish and maintain policy, procedure and process binder as it relates to utilization review and discharge planning.
- Performs other duties as assigned.