Interqual Jobs in Texas (NOW HIRING)

RN Transfer - PRN - Varies - Patient Intake Care

DHR Health - US:TX:Edinburg - Varies

Summary:

POSITION SUMMARY:

Coordinates all admissions including interfacility transfers, and screens for appropriateness of admissions – targeting specific admission criteria requirements and medical necessity for admission. Utilizes Interqual-screening criteria for all admissions and observation status patients. Obtains physicians orders prior to admission. Utilizes Interqual Criteria for screening transfers into the facility. Must possess a thorough knowledge of hospital 3rd party reimbursement rules and regulations. Assists in the identification of appropriate utilization of resources across the continuum of care.

Works collaboratively with interdisciplinary staff internal and external to the organization, and participates in quality improvement and evaluation processes related to the management of patient care.

POSITION EDUCATION/ QUALIFICATIONS:

· Licensed Register Nurse is required.

· Current license/valid permit to practice in the State of Texas will be required of all certified individuals.

· Candidate must demonstrate proficiency in both the English and Spanish language.

JOB KNOWLEDGE/EXPERIENCE:

· Knowledge in the areas of case management and utilization management, experience with Managed Care and utilization management as it relates to third-party payers preferred.

· Three to five years clinical experience is required, with experience in a Hospital or acute care setting being strongly preferred

· Experience in use of InterQual and or Milliman criteria and review processes highly desirable.

· Knowledge and understanding of Medicare and Medicaid guidelines and regulations pertaining to utilization review and discharge planning.

Responsibilities:

POSITION RESPONSIBILITES:

1. Assists in the development and implementation of the case management program.

· Collaborates with already existing programs and departments to ensure appropriate resource utilization by all patients being followed in a caseload.

· Works with nurse managers, other clinical departments, and division directors in program development.

· Establishes and/or attempts appropriate caregiver forums to provide program teaching/information and seeks program effectiveness feedback.

· Provides orientation and ongoing education specific to case management.

· Participates in extending case management approach.

· Acts as a consultant to all disciplines specific to case management program.

· Performs ongoing evaluation of case management program.

Meets Criteria :

· Participates in daily rounds, providing education to other team members

· Provides follow-up to system issues and reports individual practitioner variances appropriately to PA or Department Director.

· Participates in respective nursing unit meetings.

2. Directs, coordinates, and provides case management to patients in caseload.

· Assesses the patients within the caseload to identify needs, issues, resources, and care goals.

· Through proper reporting mechanisms, completes case management assessment, reviews admitting diagnoses/problem(s), determines plan to address client's needs, and optional/preferred level of care. Develops a discharge plan early on in admission.

· Implements and coordinates interventions that will lead to goals in plan.

· Monitors the effectiveness of the plan.

· Participates in case finding and preadmission evaluation screening to ensure reimbursement.

· Identifies potential transition planning problems in a timely manner to set up services required.

· Works with attending physician and care team members to move patient through the hospital system and set up appropriate services or referrals.

· Identifies need for new resources if gaps exist in service continuum and initiates creative care delivery options.

· Daily responsibilities:

· Reviews the medical records of all observation and inpatient admissions to determine the medical necessity for admission and continued stay, using pre-established criteria (InterQual or Milliman) with appropriate frequency and Obtain physician's orders if necessary.

· Continues review of all patients using criteria and determines need for continued hospitalization based upon third party payer/insurance guidelines.

· Assesses clinical, including psychosocial, system parameters.

· Establishes planning to determine goals and objectives and care setting to optimally meet patient needs. Develops a discharge plan in a timely manner.

· Conducts necessary conferences and team meetings regarding specific patient needs.

· Implements interventions that lead to the patient accomplishing goals established in plan.

· Coordinates the necessary resources to accomplish goals developed in plan.

· Proactively affects system to facilitate efficient flow of care.

· Gathers information from sources to enable case manager to monitor the plan's effectiveness.

· Evaluates the effectiveness of the plan (including variance) in reaching patient's outcomes and goals.

· Makes appropriate changes to plan as necessary.

· Coordinate interfacility transfer request as per policy.

· Meets Criteria:

· a. Documents patient/patient representative understanding of case management plan.

· b. Documents avoidable day and /or delay in service variances as per policy.

· c. Recognizes and immediately intervenes in cases of suspected abuse or neglect.

· d. Recognizes National Patient Safety Goals and Core Measures as applicable to the patient populations served.

3. Plays an essential role in assisting physicians, nurses, and staff with an accurate determination of a patient's observation status. The case manager is an important resource in preventing delayed discharges of observation patients.

· Identifies and monitors observation admissions daily, to determine the correct patient status.

· Consults with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient.

· Assumes the role of review coordinator for observation services; reviews medical record for appropriateness of status and level of care and facilitates the level of care, utilizing InterQual or Milliman for observation.

· Works with physicians, nurses, staff, patients, and families to arrange prompt and safe discharge.

· Must take telephone orders from physicians changing patient status from observation to inpatient admission. This should be done when monitoring observation status. A call or page should be made to a physician if the case manager believes that this should be an inpatient admission and should not wait until the 24 hours are ending before conversion. Case managers must actively monitor patients on observation status and seek to clarify their status as close to the 24-hour benchmark as possible.

· Develops a discharge plan with nursing when appropriate.

Meets Criteria:

· Accurately applies InterQual or Milliman criteria 95% of the time in determining status. Refers appropriately to the PA when medical decision making determination is necessary.

· Consistently follows Condition Code 44 policy when IP status requires changing to Observation for Medicare patients 95% of the time.

· Consistently follows the Observation policy for all other payers. (correct determination of start time)

4. Reviews the medical records of all inpatient admissions to determine the medical necessity for admission and continued stay, using pre-established criteria.

· Identifies cases that fail daily to meet criteria and refers these cases to appropriate physician advisor.

· Assists and educates attending physicians on an on-going basis.

· Contacts the attending physicians daily on cases that lack adequate documentation warranting acute hospitalization.

· Contacts the attending physician to notify him or her of the decision to issue notice of non-coverage. Explains UR process and insurance coverage requirements. Obtains physician's written concurrence when necessary.

· Informs the patient and/or next of kin when insurance coverage must be terminated for the current admission. Issues HINN letter.

· Reinstates insurance coverage when the patient's condition becomes acute and meets criteria again. Issues reinstatement letter.

· Continues review of all patients using criteria and determines need for continued hospitalization based upon third party payer/insurance guidelines.

Meets criteria:

· The initial review applying InterQual criteria is completed within 24 hours of admission.

· Continued Stay Review is completed no greater than every 48 hours (72 hours for Critical Care) or more frequently as dictated by discharge screening criteria.

· Document timeframe for next review 95% of the time.

· Proceeds to issue Hospital Issued Notice of Non-coverage and Hospital Requested Review for Medicare patients according to policy.

· Refers cases not meeting criteria appropriately, following contract requirements for all other payers.

5. Collaborates with Quality Management Department: Performs quality assessment reviews and studies both concurrently and