Registered Nurse- Care Coordinator-Forbes

Job ID: J118434
Company: Allegheny Clinic
Location: Monroeville, PA, United States
Facility: Forbes Hospital
Full/Part Time: Full time
Job Type: Regular
Posted at: Apr 30, 2018

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Description

GENERAL OVERVIEW:

Registered nurse who is proficient in the coordination of care and manages coordination of care in accordance with recognized standards of practice for Care Management. Professional role model utilizing expertise in care management to promote a collaborative professional environment that supports excellence of care and achievement of optimal resource utilization. Also facilitates appropriate LOS, patient satisfaction and reimbursement for all patients.

ESSENTIAL RESPONSIBILITIES:

  • Assumes role in assessment of patient physical, psychosocial, and economic needs for effective transition of care planning to a variety of levels of care.
  • In collaboration with the care team, facilitates the development and communication of the continuum of care transition plan to appropriate health service providers.
  • Documents, verifies, and validates specific data required to monitor and evaluate interventions and outcomes. Interviews and collects patient specified data and chart review related to readmission.
  • Knowledgeable of and complies with accreditation and regulatory requirements. Integrates performance improvement principles and customer service principles into all aspects of job responsibilities.
  • Obtains or ensures acquisition of appropriate pre-certification authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party guidelines. Obtains or facilitates acquisitions of urgent / emergent authorizations, continued stay authorizations and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements.
  • Documents, monitors, intervenes/resolves and reports clinical denials/appeals and retrospective payer audit denials. Collaboratively formulates plans of action for denial trends with the care coordination teams, performance improvement teams, physicians/physician advisor and third party payers.
  • Maintains a working knowledge of care management, care coordination changes, utilization review changes, authorization changes, contract changes, regulatory requirements, etc. Serves as an educational resource to all AHN staff regarding utilization review practice and governmental commercial payer guidelines. Adheres to the policies, procedures, rules, regulations and laws of the hospital and all federal and state regulatory bodies. Communicates telephonically and electronically with the outpatient providers in an effort to enhance the continuum of care.
  • Assumes responsibility for AHN required continued education and own professional growth. Performs other duties as assigned or required.

QUALIFICATIONS:

Minimum

  • BA/BS degree and nursing diploma. Current employees grandfathered.
  • 2-3 years of recent clinical RN acute care experience
  • Current PA RN license
  • Nationally recognized Care Management Certification within 5 years of start date (3 years for currently employed)
  • CPR Certification

Preferred

  • Discharge planning and community resource knowledge
  • Care facilitation and utilization review experience

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
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