RN Level 1

Description:

Job Summary:

This position is responsible for performing RN initial and continued stay inpatient reviews using established guidelines to ensure appropriate level of care as well as planning for the transition to the continuum of care. Performs duties and inpatient concurrent reviews as assigned by management.

Responsibilities:

Assesses patient's clinical need Products established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay. Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided. Performs initial and continued stay reviews utilizing MCG or Medical Policy Criteria. Monitors and coordinates services rendered outside of the network, as well as outside the local area, and negotiate fees for such services as appropriate. Coordinates with patient, family, physician, hospital and other external customers with respect to the appropriateness of care from diagnosis to outcome. Coordinates the delivery of high quality, cost-effective care supported by clinical practice guidelines established by the plan addressing the entire continuum of care. Monitors patient's medical care activities, regardless of the site of service, and outcomes for appropriateness and effectiveness. Documents accurately and comprehensively based on the standards of practice and current organization policies. Interacts and communicates with multidisciplinary teams either telephonically and/or in person striving for continuity and efficiency as the member is managed along the continuum of care. Understands fiscal accountability and its impact on the utilization of resources, proceeding to self-care outcomes. Evaluates care by problem solving, analyzing variances and participating in the quality improvement program to enhance member outcomes. Completes other assigned functions as requested by management.

Education/Experience:

Requires an associate-s or bachelor-s degree (or higher) in nursing and/or a health related field OR accredited diploma nursing school. Requires a minimum of two (2) years clinical experience. Utilization Management Only RNs are required to work a specified number of weekends and holidays to meet Regulatory and Accrediting body standards. Requirements may vary based on departments business needs. Additional licensing, certifications, registrations:

Active Unrestricted NJ RN License Required Knowledge:

Prefers proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint and Outlook) prefers knowledge in the use of intranet and internet applications. Prefers working knowledge of principles of utilization management including experience utilizing MCG criteria to determine medical necessity. Prefers basic knowledge of health care contracts and benefit eligibility requirements. Prefers knowledge of hospital structures and payment systems.

Skills and Abilities:

Analytical Compassion Interpersonal & Client Relationship Skills Judgment Listening Planning/Priority Setting Problem Solving Team Player Time Management Written/Oral Communication & Organizational Skills