Duties :
Screens ED patients, using Milliman criteria, for level of care appropriateness based on medical necessity determination (admission, observation, TCU / SNF, discharge).
Work with ED physicians, ED social worker, and Hospitalists to determine appropriate level of care. Identifies patients presenting to the ED who were discharged within the previous 30 days.
Complete PRIs to facilitate patient transfer to appropriate setting. Serves as a liaison between the patient and facility / physician to ensure a continuum of quality patient care throughout the hospitalization.
Assesses, plans, oversees, and evaluates the appropriateness of care throughout admission and hospitalization of the patient.
Performs concurrent utilization management using evidence based medical necessity criteria. Submits data to management regarding case management and / or quality initiatives.
Serves as an in-patient liaison - planning, assessing, implementing, and evaluating patient in collaboration with the health care team.
Conducts chart review for appropriateness of admission, facilitates throughput and completes PRIs as necessary. Conducts clinical reviews and interacts with third party payers to obtain approval of hospital days, pre-certification, and post-discharge eligibility in relation to clinical course.
Ensures compliance with current state, federal, and third-party payer regulations. Performs related duties as required.
Qualifications :
Bachelor’s degree required. NYS Registered Nurse License required. Minimum 5 years clinical nursing experience required, PRI certification preferred.
Case Management experience preferred.
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