Live In Cigna Utilization Review Nurse Jobs in Rochester, NY

Job Title: Nurse Navigator (Part-Time) - Oncology
Department: Lipson Cancer Institute
Location: Lipson Cancer Center at Rochester General Hospital with infrequent float to Unity Hospital
Hours Per Week: 32
Schedule: Monday- Friday 8am-4:30pm
SUMMARY: Provides proactive case coordination/patient navigation for patients, including triage management, algorithm management, utilization management and resource management. Organizes services across the continuum from pre-registration through discharge from the Center to affect optimal patient outcomes, achieve continuity and quality of care, reduces cost and provide customer satisfaction. Provides assistance to patients and families through evaluation of social, emotional and financial needs and coordinates and facilitates appropriate resources. Communicates with third party payors, follows Health System policies and procedures, and assist with continually improving the quality and effectiveness of case management/patient navigation.
RESPONSIBILITIES:
Reviews the medical record with referring provider as soon as possible after admission-within the first12 to 24 hours. Applies utilization review criteria to assess and document appropriateness of admission, continued stay and level of care.
Interviews patients and/or family members to obtain information about social, emotional, and financial factors which impact health status. Assesses needs for progress along department algorithm of care and continuing care or resource support following discharge.
Responds to referrals from patients, families, physicians, hospital staff, and community agencies. Collaborates with patient/family and members of health care team to develop appropriate post-hospital plans for continuing care or resource support following discharge. Utilize all appropriate medical, social, and financial resources available to support the patient/family and to ensure smooth transition to appropriate levels of care.
Responds to referrals from patients, families, physicians, hospital staff, and community agencies. Collaborates with patient/family and members of health care team to develop appropriate post-hospital plans for continuing care, to initiate referrals.
Proactively identifies problems with utilization of resources and assures specific tests, consults etc. are done in a timely manner. Feedback is obtained and documented in the patient chart. Forward patient chart to physician for review when problems are identified. Intercedes with appropriate department or attending physician to identify cause. Communicates as needed with Physician Advisor, assures patient is placed on clinical pathway and monitors variances from pathway as appropriate.
For Spine: Provides counseling, social support, and assistance in crisis situations. Proactively establishes and coordinates patient care conferences if there are care plan batteries, etc. These conferences are to coordinate continuing care plans, monitors plans, and assesses potential need for alterations of plan due to patient's changing medical condition or social/financial support system.
Maintains current information on community resources, third party payors, and managed care environment. Knowledgeable of changing rules/regulations, and policies/procedures. Maintains established departmental policies and procedures, objectives, quality management plan, environmental and infection control standards.
Maintains appropriate and timely documentation through medical record entries, daily logs, computer entries, and monthly statistics. Prepares and maintains required documentation on each patient.
Completes worksheets, communicates in a timely manner with physicians and coders, provides necessary statistics for data collection, and identifies case mix issues.
May provide consultation and education to medical and hospital staff of inpatient and outpatient programs regarding role of case management. This may include appropriate management of resources, discharge planning and complex medical/legal issues.
Assists in development of new services or policies appropriate to patient needs and consistent with strategic plan
Makes referrals to administrative director, medical director, quality management, risk management, infection control, and hospital departments when potential quality problems are identified. Refers to and consults with clinical social worker on patients with complex psychosocial/financial needs. Develops and maintains professional working relationship with medical staff, hospital staff, and coworkers.
Maintains strict confidentiality at all times.
Ensures that quality of patient care is maintained by collecting quality indicators and clinical path variance data, as well as identifying data that indicates potential areas for improvement. Participates actively on clinical pathway, CQL, and clinical process improvement teams. May act as team member, team leader, facilitator, or recorder.
Provides services, supports or other assistance in a culturally sensitive manner responsive to the patient/families beliefs, attitudes, language and behaviors.
Provides care appropriate to each patient.
Develop and maintain strong working relationships with all key internal stakeholders including physicians and center leadership.
Ensure strict adherence to all established Unity processes, procedures and standards.
REQUIRED QUALIFICATIONS:

• Current licensure as an RN in the state of New York.

PREFERRED QUALIFICATIONS:

• Nursing experience in oncology strongly preferred.

EDUCATION:
AS: Nursing (Required)
LICENSES / CERTIFICATIONS:
BLS - Basic Life Support - American Heart Association (AHA)American Heart Association (AHA), RN - Registered Nurse - New York State Education Department (NYSED)New York State Education Department (NYSED)
PHYSICAL REQUIREMENTS:
M - Medium Work - Exerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently, and/or greater than negligible up to 10 pounds of force constantly to move objects; Requires frequent walking, standing or squatting.
For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.
Any physical requirements reported by a prospective employee and/or employee's physician or delegate will be considered for accommodations.
PAY RANGE:
$80,753.00 - $110,292.00
CITY:
Rochester
POSTAL CODE:
14625
The listed base pay range is a good faith representation of current potential base pay for a successful full time applicant. It may be modified in the future and eligible for additional pay components. Pay is determined by factors including experience, relevant qualifications, specialty, internal equity, location, and contracts.
Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.