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Coordinates and manages the care of complex patients to facilitate achievement of quality patient outcomes. Performs utilization functions for appropriateness of admissions and continued hospital stay. Communicates with third-party payors, as needed, to assure reimbursement. Communicates appropriately with other care givers as needed.


JOB SPECIFIC RESPONSIBILITIES:

• Screen admissions each day to identify appropriate level of management required for each
patient for the service area covered. Review new admissions, applying medical necessity
criteria, and develop an anticipated discharge date for the assigned units/rooms.
• Prepares to discuss patients with length of stay greater than 20 days and difficult discharges
with the Managed Care Committee members on Wednesdays.
• Assist and facilitate coordination of comprehensive, individualized plan of care in collaboration
with interdisciplinary team.
• Utilize CCM for documentation of Reviews, Appropriateness of admission and continued stay,
Avoidable days, Denials, Interdisciplinary communication.
• Monitor and facilitate appropriate utilization of resources.
• Perform review functions for appropriateness of admission and continued hospital stay using
Cerner Care Management (CCM)/InterQual criteria.
Works with Emergency Room staff to facilitate transfer of patients needing lower levels of care
to appropriate facilities.
• Work with Emergency Room Staff to develop strategies to decrease Emergency Department use
by individuals identified as "frequent users" and to find community resources for these patients.
• Lead unit huddles (per unit guidelines) with Social Services to discuss discharge needs/ barriers
and anticipated discharge dates.
• Collaborate with the interdisciplinary team to formulate a safe, efficient discharge plan based on
the patient’s needs and payer requirements.


EDUCATION AND EXPERIENCE:

• Must have current license as a Registered Nurse in the State of Texas
• Bachelor’s degree in Nursing preferred.
• Minimum of five (5) years clinical nursing experience preferred.


REQUIRED LICENSURES/CERTIFICATIONS/REGISTRATIONS:

Current licensure from Texas State Board of Nurse Examiners.


SKILLS AND ABILITIES:

Good negotiation and communication skills required for high-level discussions with providers, payers, patients/families, and all other team members. Excellent and efficient typing skills a must with the ability to learn and navigate through multiple software systems, multiple times daily. Time management, organizational, and prioritization skills a must. Leadership skills needed for leading daily huddles and driving safe, efficient discharges.


INTERACTION WITH OTHER DEPARTMENTS AND OTHER RELATIONSHIPS:

This position requires close interaction with the medical staff, nursing staff and ancillary areas in order to promote a quality multi-disciplinary approach to patient care.


PHYSICAL CAPABILITIES:

Work is of medium demand; walking, sitting and standing most of the time while on duty.


ENVIRONMENTAL/WORKING CONDITIONS:

Works in a well lighted, heated and ventilated building. Hours may vary to accommodate needs in the department as prescribed by the philosophy of the hospital. Exposure to blood born pathogens is of low risk.

UMC Health System provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment on the basis of race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

Request for accommodations in the hire process should be directed to UMC Human Resources.​