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RN PATIENT NAVIGATOR - Utilization Review job

Mercy Health SystemJanesville, WI
Mercy Health System jobs

Company

Salary

Skills

Benefits

Job Description

JOB SUMMARY The Patient Navigator coordinates and facilitates patient care activities to assure appropriateness of services and efficient utilization of resources, improve coordination of care across the health care continuum, and to contribute to improved patient satisfaction and outcomes. ESSENTIAL DUTIES AND RESPONSIBILITIES# Provides case management, advocacy, and care coordination services to hospital patients in a variety of settings to assure seamless transitions in care while minimizing any associated delays or risk of readmission. Conducts early patient assessment, by case-finding and referral, to identify coordination and discharge planning needs. Creates individualized, patient -focused plan for meeting continuing care needs. Makes referrals to post-hospital care providers utilizing knowledge of community resources. Collaborates with the healthcare team to ensure discharge is timely, patient education and instructions are complete, and appropriate follow-up is established. Utilizes current clinical nursing knowledge to effectively educate patients and families about chronic disease conditions. Collaborates with staff nurses and physicians to ensure all elements for core measures have been met prior to discharge. Conducts clinical review process according to Utilization Management Plan. Identifies and intervenes in situations that pose financial risk to the patient and the organization. Floats between Harvard and Janesville as needed. AGE OF PATIENT POPULATION################### ### Neonate Child Adolescent Adult###### Geriatric COMPETENCIES################### ### Quality # Follows policies and procedures; Adapts to changes in the environment; demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance. Assesses patients for transition and discharge needs within established time frame. Monitors patient progress toward goals, according to clinical pathways and established criteria by reassessment.# Initiates referrals to post-acute providers and provide all needed information for continuing care. Utilize EMR tools to ensure discharge, medication and disease-specific education is provided and follow-up appointments are scheduled. Complete discharge phone calls within established time frames to evaluate patient understanding of and compliance with discharge instructions, medication regime and disease-specific education. Identify and refer socially complex and other appropriate patients to Social Work staff. Assists physician with determining medical necessity for admission and appropriate billing status utilizing established criteria and secondary review, as well as knowledge of payor requirements. Submits appropriate clinical review information to 3rd party reviewers on a timely basis, tracking responses and authorizations. Work conforms to regulatory guidelines and is documented appropriately. Service # Responds promptly to requests for service and assistance: Meets commitments; Abides by MHS confidentiality and security agreement; Consistently strives for excellence in service to patients and partners;. Demonstrates professionalism in manner, appearance and accountability. Shows respect and sensitivity for cultural differences, beliefs and values. Partnering # Coordinate/participate in care conferences and rounds. Participates in unit-based education, meetings, and committees. Participates in peer review, performance improvement activities and in development of clinical pathways. Maintains positive attitude and contributes to building a positive team spirit. Generates suggestions for improving work. Supports organization#s goals and values; Exhibits objectivity and openness to other#s views; Gives and welcomes feedback. Cost # Identifies, tracks and intervenes with utilization issues and care coordination issues to minimize avoidable days. Follows CMS regulations for informing patients of financial liability. Participates in initiatives to reduce readmissions. Prioritizes work so as to complete assigned duties in a timely manner. Maintains flexibility in scheduling; Conserves organization resources. EDUCATION, TRAINING, # EXPERIENCE# Graduate of accredited school of nursing.# Bachelor#s degree (BSN) required (or currently enrolled in a BSN program). Five years related experience and/or training in acute care setting. CERTIFICATION/LICENSURE################### ### Current Wisconsin Registered Nurse License. Current Illinois Registered Nurse License. CPR certification. Case Management Certification (ACM) preferred. Certification required within three years to a specialty approved by CNO or designee; i.e.; Case Management, Med/Surg or Diabetic Education. ADDITIONAL REQUIREMENTS Passing the Driver#s License Check and/or Credit Check (for those positions requiring) Passing the WI Caregiver Background Check and/or Illinois Health Care Workers Background Check Must be able to follow written/oral instructions. OTHER SKILLS AND ABILITIES Phone Skills Must be skilled with use of voice mail and phone features. Must be able to use available technology for language interpretation..################## # Computer Skills Must have expert knowledge of Allscripts Care Management program and Epic EMR. Must be able to use Microsoft Outlook, and have basic knowledge of Excel and Word. Must be able to easily toggle between computer applications. OTHER QUALIFICATIONS Must be available to work and or be on-call on weekends and holidays, as assigned. On-call requires accessibility by pager or cell phone during assigned hours and ability to respond promptly to pages by phone. WORK ENVIRONMENT################### ### The noise level in the work environment is usually moderate. Occupational Exposure is category C which means no employees in the specified job classifications have occupational exposure INFORMATION ACCESS Partner may access patient care information and financial data needed to perform job duties.# The Case Manager abides by all confidentiality and security policies of the organization related to information access. WORK CONTACT GROUP# Patients, families, physicians, nurses, social workers, ancillary services External: insurance and review agencies, community and government agencies, continuing care health providers SPECIAL PHYSICAL DEMANDS################### ### While performing the duties of this Job, the employee is frequently required to sit, handle, finger, feel, reach with hands and arms, talk and hear. The employee is occasionally required to stand, walk, climb and balance. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include frequent close vision, distance vision, and the ability to adjust focus as well as occasional color vision, peripheral vision and depth perception. . Specific fine motor abilities required include writing, keyboard entry and mouse use. The Special Physical Demands are considered Essential Job Function of the position with or without reasonable accommodations. LEVEL OF SUPERVISION################### ### Assignments are based on abilities and are normally received in the form of results expected and due dates.# Only general procedures are available to guide work.# Must be able to work independently with minimal guidance. SUPERVISES################### This job has no supervisory responsibilities.

JOB SUMMARY

The Patient Navigator coordinates and facilitates patient care activities to assure appropriateness of services and efficient utilization of resources, improve coordination of care across the health care continuum, and to contribute to improved patient satisfaction and outcomes.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Provides case management, advocacy, and care coordination services to hospital patients in a variety of settings to assure seamless transitions in care while minimizing any associated delays or risk of readmission. Conducts early patient assessment, by case-finding and referral, to identify coordination and discharge planning needs. Creates individualized, patient -focused plan for meeting continuing care needs. Makes referrals to post-hospital care providers utilizing knowledge of community resources. Collaborates with the healthcare team to ensure discharge is timely, patient education and instructions are complete, and appropriate follow-up is established. Utilizes current clinical nursing knowledge to effectively educate patients and families about chronic disease conditions. Collaborates with staff nurses and physicians to ensure all elements for core measures have been met prior to discharge. Conducts clinical review process according to Utilization Management Plan. Identifies and intervenes in situations that pose financial risk to the patient and the organization. Floats between Harvard and Janesville as needed.

AGE OF PATIENT POPULATION

Neonate

Child

Adolescent

Adult

Geriatric

COMPETENCIES

Quality - Follows policies and procedures; Adapts to changes in the environment; demonstrates accuracy and thoroughness; Looks for ways to improve and promote quality; Applies feedback to improve performance. Assesses patients for transition and discharge needs within established time frame. Monitors patient progress toward goals, according to clinical pathways and established criteria by reassessment. Initiates referrals to post-acute providers and provide all needed information for continuing care. Utilize EMR tools to ensure discharge, medication and disease-specific education is provided and follow-up appointments are scheduled. Complete discharge phone calls within established time frames to evaluate patient understanding of and compliance with discharge instructions, medication regime and disease-specific education. Identify and refer socially complex and other appropriate patients to Social Work staff. Assists physician with determining medical necessity for admission and appropriate billing status utilizing established criteria and secondary review, as well as knowledge of payor requirements. Submits appropriate clinical review information to 3rd party reviewers on a timely basis, tracking responses and authorizations. Work conforms to regulatory guidelines and is documented appropriately.

Service - Responds promptly to requests for service and assistance: Meets commitments; Abides by MHS confidentiality and security agreement; Consistently strives for excellence in service to patients and partners;. Demonstrates professionalism in manner, appearance and accountability. Shows respect and sensitivity for cultural differences, beliefs and values.

Partnering - Coordinate/participate in care conferences and rounds. Participates in unit-based education, meetings, and committees. Participates in peer review, performance improvement activities and in development of clinical pathways. Maintains positive attitude and contributes to building a positive team spirit. Generates suggestions for improving work. Supports organization's goals and values; Exhibits objectivity and openness to other's views; Gives and welcomes feedback.

Cost - Identifies, tracks and intervenes with utilization issues and care coordination issues to minimize avoidable days. Follows CMS regulations for informing patients of financial liability. Participates in initiatives to reduce readmissions. Prioritizes work so as to complete assigned duties in a timely manner. Maintains flexibility in scheduling; Conserves organization resources.

EDUCATION, TRAINING, & EXPERIENCE

Graduate of accredited school of nursing. Bachelor's degree (BSN) required (or currently enrolled in a BSN program). Five years related experience and/or training in acute care setting.

CERTIFICATION/LICENSURE

Current Wisconsin Registered Nurse License.

Current Illinois Registered Nurse License.

CPR certification.

Case Management Certification (ACM) preferred.

Certification required within three years to a specialty approved by CNO or designee; i.e.; Case Management, Med/Surg or Diabetic Education.

ADDITIONAL REQUIREMENTS

Passing the Driver's License Check and/or Credit Check (for those positions requiring)

Passing the WI Caregiver Background Check and/or Illinois Health Care Workers Background Check

Must be able to follow written/oral instructions.

OTHER SKILLS AND ABILITIES

Phone Skills

Must be skilled with use of voice mail and phone features. Must be able to use available technology for language interpretation..

Computer Skills

Must have expert knowledge of Allscripts Care Management program and Epic EMR. Must be able to use Microsoft Outlook, and have basic knowledge of Excel and Word. Must be able to easily toggle between computer applications.

OTHER QUALIFICATIONS

Must be available to work and or be on-call on weekends and holidays, as assigned. On-call requires accessibility by pager or cell phone during assigned hours and ability to respond promptly to pages by phone.

WORK ENVIRONMENT

The noise level in the work environment is usually moderate.

Occupational Exposure is category C which means no employees in the specified job classifications have occupational exposure

INFORMATION ACCESS

Partner may access patient care information and financial data needed to perform job duties. The Case Manager abides by all confidentiality and security policies of the organization related to information access.

WORK CONTACT GROUP

Patients, families, physicians, nurses, social workers, ancillary services

External: insurance and review agencies, community and government agencies, continuing care health providers

SPECIAL PHYSICAL DEMANDS

While performing the duties of this Job, the employee is frequently required to sit, handle, finger, feel, reach with hands and arms, talk and hear. The employee is occasionally required to stand, walk, climb and balance. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include frequent close vision, distance vision, and the ability to adjust focus as well as occasional color vision, peripheral vision and depth perception. . Specific fine motor abilities required include writing, keyboard entry and mouse use.

The Special Physical Demands are considered Essential Job Function of the position with or without reasonable accommodations.

LEVEL OF SUPERVISION

Assignments are based on abilities and are normally received in the form of results expected and due dates. Only general procedures are available to guide work. Must be able to work independently with minimal guidance.

SUPERVISES

This job has no supervisory responsibilities.
Estimated annual salary
$69,028
average
Minimum
$56,296
Maximum
$79,955

TASKS

  • Maintain accurate, detailed reports and records.
  • Administer medications to patients and monitor patients for reactions or side effects.
  • Record patients' medical information and vital signs.
  • Monitor, record, and report symptoms or changes in patients' conditions.

SKILLS

  • Reading ComprehensionUnderstanding written sentences and paragraphs in work related documents.
  • Active ListeningGiving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
  • WritingCommunicating effectively in writing as appropriate for the needs of the audience.
  • SpeakingTalking to others to convey information effectively.

KNOWLEDGE

  • Customer and Personal ServiceKnowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
  • Computers and ElectronicsKnowledge of circuit boards, processors, chips, electronic equipment, and computer hardware and software, including applications and programming.
  • MathematicsKnowledge of arithmetic, algebra, geometry, calculus, statistics, and their applications.
  • BiologyKnowledge of plant and animal organisms, their tissues, cells, functions, interdependencies, and interactions with each other and the environment.
Health Insurance

Mercy Health System

Type

Hospital

Size

Large

Revenue

$500M to $1B

Location

Janesville, WI, and others

Industry

Hospitals

Founded

1918

CEO

Javon Bea President

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