Essential Job Functions

• Utilization
  • Completes initial utilization review for medical necessity for an assigned patient population.
  • Initiates assessment within 24 hours of admission or next business day.
  • Applies Interqual criteria for severity of illness/intensity of service indicators/medical necessity criteria as appropriate.
  • Recognizes and progresses the plan of care when an alternative level of care is appropriate.
  • Conducts continued stay reviews by monitoring patient's response to treatment and resource utilization.
  • Collaborates with Attending Physician and healthcare team to facilitate the progression of the plan of care.
  • Completes initial and continued stay reviews in a timely manner, in accordance with various payor contracts and guidelines.
  • Cognizant of payor requirements for all patients in assigned caseload.
  • Responsible for accurate and timely documentation in recognized data bases to support Clinical Resource Management components for each patient in assigned caseload.
• Denial Management
  • Initiates contact with Attending Physician on all cases that do not meet SI/IS indicators to clarify plan of care.
  • Educates physicians and other members of the healthcare team on the application of Interqual criteria to support an Acute Level of Care and provide alternatives to acute care as appropriate.
  • Encourages and coaches the Attending Physician to participate in third party payor appeal process when necessary.
  • Notifies the Manager of all real or potential cases in which an adverse determination has been rendered or is anticipated by the payor.
  • Identifies and facilitates transition to an alternate level of care.
• Discharge Planning
  • Assesses, plans, and facilitates appropriate discharge plans for assigned patient caseload with collaboration from the patient/family, physician, and other members of the healthcare team.
  • Coordinates alternate levels of care based on the patient’s current needs and availability of healthcare resources.
  • Creatively resolves complicated disposition issues, utilizing community resources with the integration of the patient's available benefits to achieve a positive outcome.
  • Provides information for appropriate referrals to patients and their families, and provides counseling on a limited basis.
• Maintains patient rights by adhering to HIPPA, Freedom of Choice, Rights of Reconsideration, and other regulatory agency requirements.

Specialty Job Functions

• Exhibits active positive communication/collaboration with appropriate internal and external agencies.
  • Daily interactions with case workers, nursing and physicians to identify barriers and explore alternatives that may contribute to a delay in discharge.
  • Formulate appropriate discharge plans for patients that meet patient needs and MCO standards.
• Provide ongoing education for patients, staff, families, and physicians on managed care changes.
  • Facilitate quarterly in services to staff.
  • Orient new employees to their role in a managed care environment.
• Maintain an active knowledge base of managed care organization (MCO) standards.
  • Demonstrate awareness of preauthorization’s for prescription medications and patient transportation.
  • Attends seminars as needed to obtain updated information.
• Utilization
  • Collaborates with manager and physicians as needed to assure proper utilization of patient days.
  • Accurate documentation in Midas System.
  • Communicates pertinent issues on patients to billing department.
  • Actively collects data for performance improvement activities.
• Other related duties as assigned.

Required Qualifications

• Graduate of an accredited Nursing Program required.

• One (1) year clinical experience, preferably in behavioral health acute inpatient setting.
• Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment, and knowledge of legal aspects and liability of nursing practice.
• Knowledge of Payor/Insurance Benefits

• Functional Skills on PC and Related Software (Microsoft Office)
• Knowledge of basic Office Equipment such as copier, fax machine, etc.
• Excellent communication, interpersonal and organizational skills
• Analytical problem-solving skills, sound judgment; excellent oral and written communication skills, must be able to function in a team environment.
• Ability to communicate with all members of the health care team
• Ability to multi-task and prioritize assignments

• Strong organizational and time management skills; ability to work independently and in a team setting.
• Excellent negotiation skills. Strong analytical, data management.
• Current working knowledge of utilization management, case management and discharge planning.
• Current working knowledge of community resources, post-acute services.

Preferred Qualifications

• Bachelor’s Degree in Nursing preferred.
• Recent Case Management experience preferred.
• Three (3) years’ experience in the field of psychiatric nursing or social work.

License, Certification & Clearances

• Current licensure to practice as a Registered Nurse in the State of Pennsylvania required.
• Current Basic Life Support (BLS) approved curriculum of the American Heart Association (CPR and AED) program required.

• PA Act 153 Clearances with renewal.

Supervisory Responsibilities

• This position has no direct supervisory responsibilities, but may serve as a coach and mentor for other positions in the department.

Position Type/Expected Hours of Work

• Incumbent will be scheduled based on operational need (rotate shifts, standby, on-call, etc.).
• Travel may be expected locally between Independence Health locations'/EEO

• Independence Health is an Equal Opportunity Employer. It is the policy of Independence Health to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, veteran status, or genetic information, or any other protected class. Independence Health will conform to the spirit as well as the letter of all applicable laws and regulations.
• Ability to perform the Essential Functions listed on the Physical Conditions and ability to perform the Essential Functions on the Working Condition chart below.

Work Environment

Effective March 2020 or during pandemic: goggles, face shield and mask are required according to CDC guidelines

Physical Demands

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.

Qualifications

Licenses & Certifications

Required

REGISTERED NURSE

BASIC LIFE SUPPORT

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.