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Under general direction, coordinates a continuum of care for a selected group of patients from pre-admission through post-discharge. Assures that patients and families proceed efficiently through the course of hospitalization; to move a patient through the hospital system in a cost effective manner resulting in the optimal discharge plan; and to perform other duties as assigned.
Incumbents in this class are responsible for screening patient admissions, ongoing review of patient medical records pertaining to the quality of patient care, maximizing reimbursement for services provided and provide optimal discharge planning; incumbents are located in the Utilization Review Unit of the Quality Assessment Department and report to the Utilization Review Supervisor.
Examples Of Essential Duties:
Coordinates and monitors patients through the hospitalization process utilizing physicians, primary care nurses, and third party payors to maintain quality care and fiscal responsibility.
Assists the admitting department in identifying and resolving problems regarding appropriate admissions.
Acts as a resource/advisor to physicians for adequate medical record documentation, appropriateness of facility services as they relate to diagnoses, and options for post-discharge care.
Reviews the post hospital care plan with the patient/family. Establishes a contract regarding time frames and responsibilities. Follows plan through to discharge.
Utilizes community services to provide optimal discharge planning, monitors/expedites timely completion of services to avoid delays in care or discharge, facilitate third party reimbursement approval and/or authorization, conducts post discharge activities and documentation, responsible for completion and interpretation of patient statistical reporting.
Coordinates with multi-disciplines to include Dietary, Physical Therapy, Occupational Therapy, Speech, Social Services, Infection Control, etc., to insure efficient use of hospital resources.
Answers questions from patients and their families, including providers regarding reimbursement of covered and non-covered services.
Knowledge of: Payor source documentation requirements and governmental regulations affecting reimbursement; Acute care nursing principles, methods, and commonly used medical procedures; Common patient disease processes, and the usual methods for treating them; Medical terminology, hospital routine, and commonly used equipment; Identification of potential discharge needs; Knowledge of community resources; acute care hospital organization and the interrelationship of various clinical and diagnostic services.
Ability to: Evaluate the medical records of hospital admissions; make recommendations regarding continued stay necessity, appropriateness of the level of the delivery of care; identify discharge needs; use of ancillary services, and discharge plans; communicate documentation needs in a manner that promotes cooperation; gather and analyze data and prepare reports and recommendations; Work effectively with physicians, other health providers, outside payor sources, community resources, and the general public; relate positively with patients and families; demonstrate crisis intervention skills.
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