Pediatric Utilization Review Jobs in Kansas (NOW HIRING)

Mother/Baby & Pediatric Integrated Nurse Case ManagerDays - Full TimeBell HospitalPosition Summary / Career Interest:The Integrated Nursing Case Manager, under the direction of the Director/Manager of Case Management, provides care/service safely and efficiently for a full range of services to patients of all ages and their families. Primary role is to collaborate, communicate and facilitate coordination of services during hospitalization and post-hospitalization as established by the healthcare team. RN Case Manager concurrently facilitates proactive patient care services to ensure that care is appropriate, timely, and cost-effective and achieves the desired outcome. The RN Case Manager coordinates the care and service of selected patient populations across the continuum of illness; promotes effective utilization and monitoring of health care resources; and guides all disciplines toward positive quality outcomes.

Responsibilities and Essential Job Functions

• Accepts responsibility and accountability for achievement of optimal outcomes within their scope of practice. Follows policies, procedures and standards; complies with Corporate Compliance program. Assumes responsibility for risk and safety issues associated with the position. Takes call as required by the department expectations. Performs specific job responsibilities and demonstrates accountability for own actions and decisions.
• Acquires and maintains knowledge and competence related to the expectations of their position and practices within their scope. Brings ideas and concerns to supervisor, participates in department decision making. Maintains current licensure.
• Advocates on behalf of patients and caregivers for identification and access to services. Advocates for the protection of the patient's health, safety and rights. Ensures patient choice and consistently supports a patient centered environment.
• Identifies and manages other patient needs making referrals to the appropriate personnel; validate the need was addressed.
• Identifies patient educational, social and financial needs; referring to the appropriate personnel.
• Spiritual support. Refers to Pastoral Care or their pastor.
• Assures prudent utilization of all resources (fiscal, staff resources, environmental, equipment and services) by evaluating the options available. Demonstrates ability to balance cost and quality to assure the optimal clinical and financial outcomes. Participates in performance improvement activities.
• Reviews all assigned Outpatient Observation patients and verifies correct status assignment and develops discharge plan.
• Conducts admission and continued stay reviews to evaluate medical necessity of admission/continued stay and appropriateness of treatment plan using screening criteria and benchmark tools as defined by the department. When appropriate confers with the attending physician, department management, physician advisor, and insurance companies to assure the justification of admission/continued stay
• Facilitates external payer certification for hospital and discharge needs.
• Initiates the process to move the patient appropriately through the continuum of care.
• Minimizes and informs patients of their financial responsibilities.
• Ensures compliance with payer rules and regulations.
• Monitors, records, and reports all variances related to utilization of resources.
• Communicates timely, relevant and accurate information to all parties involved with patient's care. Communicates effectively and frequently within the multidisciplinary team and patient/family throughout the hospitalization.
• Facilitates the progression of care by advancing the care plan to achieve desired outcomes. Monitors the patient's progression towards the desired outcome. Facilitates discharge planning, resource referral and patient education.
• Uses critical thinking skills to facilitate proactive discharge planning, initial discharge assessment on assigned patient population, establish daily goals, validate medical record documentation of the patient's clinical picture all as it relates to the case management process.
• Identify discharge needs such as equipment, home health services, nursing home, and etc.
• Completes education and resource referrals as appropriate.
• Facilitates transfers to a lower level of care.
• Explores discharge options and communicates to the patient, family and physician.
• Coordinates and facilitates communication among all team members, including community providers.
• Integrates the work of the healthcare team by coordinating resources and services necessary to accomplish agreed-upon goals and desired discharge plan. Continuously monitors the patient through frequent interactions starting at admission through discharge.
• Documents appropriate information in Case Management computer system, progress notes and any other required documentation.
• Prepares for and participates in daily Interdisciplinary Care Coordination (ICC) Huddles by providing relevant and discipline specific information to the entire healthcare team.
• Works collaboratively with patients, families, all members of the healthcare team, and community partners to make an appropriate discharge plan based on identified needs. The RN Case Manager and healthcare team are jointly accountable for measurable outcomes which are cost effective and reflect patient preferences and values. Participates as a member of a team to achieve organizational and departmental goals.
• Presents at the Weekly Length of Stay (LOS) Meeting on patients reaching or surpassed the assigned length of stay threshold.
• Facilitates care within the financial restraints.
• Prioritizes daily activities based on payer reimbursement, length of stay, level of care, and charges to date.
• Intervenes per hospital/department policy with potential over-utilization of clinical resources.
• Assists in the appeal process by proactively requesting reconsideration on all adverse determinations from external payers.
• Identify, escalate, and document avoidable days for reporting purposes.
• Provide crisis intervention as needed/when directed by Case Management Director/Manager. A Case Management staff member is available "on call" 24-hours a day, seven days a week. All members of the Case Management Department are expected to accept "on call" responsibilities on a monthly basis.
• Continually participates in the study and improvement of process providing health care services to meet the needs of patients, the organization and the department.
• Monitors individual patient outcomes and intervenes as necessary.
• Identifies opportunities for performance improvement and refers to the appropriate person or department.
• Identifying opportunities for Medical Staff performance improvement, collecting data, reporting variances and statistical data to the Medical Staff Performance Improvement Committee, Credentialing Committee, or any other appropriate group or team.
• Assist the medical staff department with conducting peer review activities and completion of special studies.
• Serves as a resource for the PI process, and is able to lead team and facilitate teams.
• Completes all Case Management system requirements, and assist in data analysis and identifying opportunities to improve performance.
• Monitors outcomes related to the financial impact on patient care.
• Participates in professional development activities.
• Attends workshops, conferences or seminars suggested by Manager.
• Completed the objectives identified on last performance appraisal.
• Identifies professional development needs and pursues educational opportunities.
• Participates on hospital task forces and committees.
• Attends and participates in department meetings.
• Acts as a preceptor for new team members.
• Assists in training of new team members.
• Seeks clinical supervision when needed.
• Demonstrates flexibility and teamwork among case management staff members.
• Assists peers in the event of fluxuating census.
• Provides coverage to other services as needed or as requested by Manager
• Identifies, monitors and reports opportunities for quality and performance improvement to the appropriate department. The RN Case Manager takes an active role in performance improvement activities as it relates to their area of assignment.
• Must be able to perform the professional, clinical and or technical competencies of the assigned unit or department.
• These statements are intended to describe the essential functions of the job and are not intended to be an exhaustive list of all responsibilities. Skills and duties may vary dependent upon your department or unit. Other duties may be assigned as required.

Required Education and Experience

• High School Graduate
• Bachelor Degree Nursing in Nursing

Preferred Education and Experience

• 2 or more years clinical experience in a health care setting

Required Licensure and Certification

• Licensed Registered Nurse (LRN) - Single State - State Board of Nursing Registered Nurse in State of Kansas
• Basic Cardiac Life Support (BLS or BCLS) - American Heart Association (AHA)

Time Type:Full timeJob Requisition ID:R-53992Important information for you to know as you apply:

• The health system is an equal employment opportunity employer. Qualified applicants are considered for employment without regard to race, color, religion, sex (including pregnancy, gender identity, and sexual orientation), national origin, ancestry, age, disability, veteran status, genetic information, or any other legally-protected status. See also Diversity, Equity & Inclusion.

• The health system provides reasonable accommodations to qualified individuals with disabilities. If you need to request reasonable accommodations for your disability as you navigate the recruitment process, please let our recruiters know by requesting an Accommodation Request form using this link asktalentacquisition@kumc.edu.

• Employment with the health system is contingent upon, among other things, agreeing to the health-system-dispute-resolution-program.pdf and signing the agreement to the DRP.

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