Overview: Under the direction of the Medical Director and in coordination with the quality improvement activities, the Quality Utilization Nurse is responsible for review and evaluation of clinical services provided to PACE participants.
The nurse will primarily focus on initial and concurrent reviews of in-patient hospitalization, using Interqual criteria to determine admission appropriateness, anticipated length of stay and potential discharge needs.
They appropriately and expeditiously refer cases to the Medical Director, process Medical Director decisions in the electronic medical record and notify the hospitals of determinations.
The nurse may also refer cases with quality of care concerns to the Medical Director and Quality Improvement Director and assist with quality improvement functions as needed.
This can include conducting periodic audits of PACE program processes related to clinical program requirements.
Responsibilities: Essential Functions
• Under the direction of the Medical Director and in coordination with the Quality Assurance activities, the Quality Utilization Nurse is responsible to review and evaluate clinical services provided to our members.
• Help providers give quality, evidence based care in an effort to reduce costly complications, optimize therapeutic outcomes, and improve the quality of life of our members.
• Conduct initial inpatient review and determine the appropriateness of admission, anticipated length of stay and potential discharge needs.
• Prioritize the review of patients according to the relevant clinical services policy and procedures.
• Accept telephonic and faxed reviews.
• Document inpatient review including diagnosis, procedures, attending physician, treatment plan, anticipated length of stay, and Interqual Criteria to justify continued stay
• Perform concurrent review in a timely manner.
• Assess and coordinate referrals for inter-hospital transfers and specialty care.
• Appropriately and expeditiously refer cases to the Medical Director, process Medical Director’s decision in the computer system
• Generate Approval and Denial letters based on Medical Director’s determination
• Expeditiously alert providers by phone of denials.
• Appropriately refer cases to re-insurer in a timely manner.
• Actively participate in the discharge planning process with the facility discharge planner to ensure timely discharge, appropriate follow up and continuity of care.
• Refer cases with quality of care concerns to the Medical Director and Quality Assurance Improvement Dept.
• Alert Provider Relations team regarding possible need to negotiate rates for Non-Par Providers, assure that all necessary paperwork is obtained, and appropriately document in the computer.
• Must comply with all ArchCare Senior Life policies and procedures.
• Perform follow-up phone calls to facilitate obtaining of documents for any member visit or admission to Facilities, ER and/or Hospital.
• Maintain confidentiality of all member information in compliance with HIPAA requirements.
• Accept and perform additional duties as assigned within the scope of Nursing.
• Assists with quality assurance functions as needed.
They can include but we not limited to: Conducts periodic audits of systems and processes related to clinical program requirements.
Utilizes data to support operational performance improvement initiatives.
Assists with quality improvement initiatives that seek to improve member experience with ASL.
Problem-solves with the IDT team to promote member satisfaction, retention efforts.
Makes recommendation for improvement of processes that affect member experience.
Conduct audits.
Qualifications: Education Requirements
• Required Education Experience or Associates Degree in Nursing or Diploma in Nursing with at least five years of nursing experience required.
Registered Nurse with a Bachelors Degree in Nursing preferred.Experience Requirements
• At least five years experience as a nurse in an adult acute care setting (ex.
ER, Critical Care) Experience in a Managed Care organizational environment is preferred.
If not currently working in Managed Care, requires at least three years nursing responsibilities in an adult acute care setting (ER,Critical Care) Experience in Home Health, Community Health/Outreach and Discharge Planning is a plusLicense Requirements
• Current licensure as a Registered Nurse or licensure as a Practical Nurse in New York State