Position Summary
Review and facilitation of the Continuum of Care to achieve desired clinical outcomes. Outcomes attained collaboratively with participation of patients, family members, physicians, health care providers and others.
Key Responsibilities
- Performs integrated patient care quality monitoring: Utilizes Medical Staff approved comprehensive monitors that measure/evaluate: o Operative and Invasive procedures o Peri-natal o Infection Control o Stability at Discharge o
Utilization o Case Review Immediately notifies the Quality and Accreditation Improvement Department of urgent/critical
quality issues. - Identifies cases for potential peer review and reports these cases to the Quality and Accreditation Department. Documents all screening and outcome variations according to Quality & Accreditation Department process. Assists MSMHC achieve compliance in the important functions described in the Joint Commission manual.
- Performs utilization review, regardless of payor source, in accordance with the Utilization Management Plan in accordance with State of Maryland Regulations. Utilizes Medical Staff approved monitors for ongoing measurement/evaluation of utilization management.
- Maintain current clinical records according to department policy and professional standards and prepares monthly
statistical reports. Is available on a rotating basis on weekends, evenings, and holidays with other staff to provide onsite
services from utilization review. - Performs the “denial” process for all patients according to particular payor. Advises the physician of appropriate
commercial insurer requirements, such as Medical Assistance second opinion requirement. Performs clinical review,
upon request of Patient Accounts, for appeals, and Medicaid Administrative Days. Completes appeal process for denial
days that appear to be clinically justified. - Readily distinguishes between acute, intermediate and skilled levels of care. Contacts managed care companies on a
daily basis to assure reimbursement for continued stay. Refers concurrent utilization problems/issues to the Physician
Advisor for review. - Completes, in a timely manner, admission and continues stay criteria review to obtain “certification” and/or continues
stay approval for selected Medicare, Medicaid, commercial and managed care patients. Refers individual patient
reviews that do not meet status criteria to Executive Health Resources (EHR) as per contract. - Facilitates the “Continuum of Care” through coordination of the discharge planning process: Upon referral, assess
patient discharge planning needs and social factors related to patient care. Consults with the physician(s) to obtain
essential information including the post discharge treatment plan and communicates this treatment plan to other health
care providers, internal and external, to assure the continuity of the patient’s care. - Maintains current clinical records according to department policy and professional standards and prepares monthly
statistical reports. Is available to be on site on a rotating basis on weekends, evenings and holidays with other staff to
provide discharge planning, telephone consultation, resource information and referrals for Home Health and medical
equipment. - Counsels patients and significant other regarding financial assistance and makes appropriate referrals where needed.
Assesses level of care for patients in need of long term placement and obtains appropriate placement. Coordinates long term or short term placement with the physician, patient, significant other and internal/external health care providers. - Documents assessment, discharge plan, problems, services, and outcomes in the medical record in a clear and concise manner with consideration of the patient’s age, developmental needs, diagnosis and employee area of specialization. Makes referrals and arranges for needed services for home care.
- Coordinates multi disciplinary clinical management conferences. Assists the patient and significant other in assessing
discharge options and determining a plan for continuing care within the limits of resources, personal preferences,
regulations, and medical needs. - Assures the provision of clinical social services to meet the needs of our patients and their significant others.
- Makes appropriate referrals to Pastoral Care to meet the spiritual needs of our patients and significant other. Makes
appropriate referrals to community action groups, support groups, etcetera. Complies with the State law for reporting
abuse/neglect for children and adults. - Completes a psychosocial history and assessment for patients identified as high risk that is maintained as a permanent
part of the medical record. Evaluates social and significant other information and assists in determining treatment plans
relevant to patient’s background, age, and emotional/cognitive needs. - Identifies high risk patients (through predetermined screening criteria) and makes prompt appropriate referrals to social
services/social workers. Works in concert with Social Workers/Social Services to meet the needs of our patients and
significant other. - Communicates with others in an effective, professional manner: Maintains confidentiality in accordance with hospital
policy. Maintains open communication with MSMHC staff. - Communicates effectively, courteously and compassionately with all patients, families, visitors, physicians. Utilizes
appropriate channels of communication to address interdepartmental concerns and opportunities for improvement.
Serves as patient advocate in assuring a collaborative approach to patient care management. - Medical Staff, patients, significant others, nursing and health care providers as appropriate, (internal and external) to
facilitate the case management process and enable patients to make informed decisions regarding their plan of
treatment and discharge disposition. - Participates in organizational improvement: Participates in improving processes related to the Continuum of Care,
Performance Improvement, and The Joint Commission Important Functions as appropriate. Participates in the
formulation and revision of policies and procedures related to the case management process. - Demonstrates a commitment to professionalism and self-improvement: Attends required departmental staff meetings.
Participates in the Joint Commission related educational programs. - Participates in related educational programs that promote clinical and case management expertise. Participates or
provides at least one educational program annually for SMHC staff. Accepts other related duties as assigned by the
Director.
What We Offer
- Culture- Collaborative, inclusive, diverse, and supportive work environment.
- Career growth- Career mentoring to help you pursue your passions and gain skills to enhance your value.
- Wellbeing- Competitive salary and Total Rewards benefits to help keep you happy and healthy.
- Reputation- Regional & National recognition, advanced technology, and leading medical innovations.
Qualifications
- ADN, BSN, MSN, or CNL from an accredited School of Nursing required.
- 1-2 years Experience required, 3-4 years preferred.
- Active MD RN License or Active Compact State RN and Basic Life Support for Healthcare providers required.
