RN-5 - West Union - job 1198135

Gundersen Health System

Date: 09/12/2021

City: West Union, Iowa

Employment type: Full-time


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Scheduled Weekly Hours:


40


Job Description:


Basic Function:


Purpose: As an advocate for the patient, the RN, Care Coordinator/Utilization Review assists patients to reach optimal function and health in an appropriate environment that would support their needs and performs medical necessity review of initial patient placement and continued stay review for hospitalization.


Role Definition: The RN-CC/UR functions within the full scope of nursing practice to include the major responsibilities of the position description and to extend those responsibilities beyond the episode of care to encompass coordination of care across the continuum. The continuum of care includes inpatient to outpatient to community. The length of time an RN-CC/UR would follow a patient is determined by patient needs and attainment of mutual goals.


The RN CC/UR applies nationally recognized criteria during review of patients' medical records and provides communication on review determinations to the attending physician and external review organizations as required by the patient's insurance coverage. The RN collaborates with the health care team to assure that patient needs, discharge plans, and follow up plans are documented and certified as medically necessary. Monitoring of patient progress and outcomes towards goals is a requirement.


MAJOR RESPONSIBILITIES


Utilization Revie/Care Coordination:



  1. Patient Information Analysis:



  • Uses assessment skills and appropriate risk assessment tools to identify patients with actual or potential health care needs that would require care coordination. Identifies needs for home health, hospice, home IV therapy, durable medical equipment and behavioral health treatment plans and refers to the appropriate department for follow up

  • Collaborates with patient/family in establishing mutual goals based on the patient's needs or problems

  • Applies the process of assessment, planning, implementation, monitoring, evaluation and coordination of care to meet the patient's health care needs across the continuum in collaboration with health team members to ensure safe, quality and cost effective care.

  • Explores patient's understanding and knowledge of current health status



  1. Patient observation and monitoring:



  • Applies nursing judgment to determine level of care assigned or delegated. Monitors medical necessity for inpatient or outpatient medical level of care and throughout patient's hospitalization

  • Uses knowledge of complex physiology to monitor, detect and anticipate early and subtle health status changes

  • Monitors, trends and records patient response to disease, illness, treatment.



  1. Nursing Action:



  • Accountable for individualized plan of care and its delivery.


a) Applies expertise to solve problems, generate ideas, plan care, teach and create new services


b) Assigns Standards of Care


c) Collaborates with patients about plan of care


d) Guides development of multiple health care partnerships to achieve a positive health effect.



  • Maintains purposeful therapeutic presence with patients based on nursing judgment.

  • Provides care based on patient complexity and nursing judgment.

  • Uses patient's perspective to support informed decision-making.



  1. Promotes patient wellness and facilitates healing.



  • Anticipates future needs and educates or refers to valid sources of information.

  • Understands the patient's unique perspective and assures right education, right time, and right environment for learning.

  • Evaluates outcome of learning.

  • Works collaboratively with patients and families on the Utilization Management process. Assists the patient in obtaining necessary hospital services that are within their insurance coverage or managed care contract. Works collaboratively with the interdisciplinary team to identify and improve patient flow from hospital to discharge.



  1. Delegation and supervision of assistive personnel.



  • Delegates care based on situation.

  • Fosters teamwork and respect.

  • Assures effective use of staffing resources.

  • Supports assistive personnel: Serves as a resource and holds assistive personnel accountable to complete delegated tasks



  1. Professional expectations:



  • Ascribes to the ANA Code of Ethics for professional nursing practice

  • Commits to culturally congruent care

  • Commits to continuous learning

  • Participates in education of nursing colleagues and students

  • Commits to evidence-based practice and the conduct of nursing research

  • Commits to mission, vision and values of organization and to the profession of nursing

  • Ensures compliance with all internal and external policies and procedures, including regulatory and legal requirements associated with denials and appeals processes. Works collaboratively with the Compliance Department when needed. Stays current in education with changes in reimbursement modalities, compliance or regulatory requirements, utilization management and level of care updates.



  1. Patient agent responsibilities:



  • Creates an environment that assures patient safety.

  • Promotes healing by creating an environment that conserves patient energy.

  • Instills confidence in the patient's own ability to regain/optimize their own health.

  • Partners with patient to help them integrate health status changes into their life.



  1. Quality Improvement & Outcome Activities



  • Provides consultation and guidance to medical staff in making medical level of care determinations utilizing RN training and work experience. May also develop training resources for others related to Utilization Management trends, guidelines, and processes.

  • Continually evaluates the data to further refine the referral criteria

  • When appropriate, integrate care coordination with disease management efforts to achieve low cost interventions that achieve the greatest benefit and increase the accountability of patients for management of their disease.

  • Documents in the department database the outcome of all medical necessity reviews including external government auditors and insurance company denial and appeal outcomes

  • Works collaboratively with Revenue Cycle regarding any patient issues in regards to billing or admission or registration.

  • Participates in process improvement projects and performance measurements.

  • As assigned, may assist with the development and implementation of programs, policies, and procedures by utilizing RN experience and knowledge.


SCOPE OF THE JOB


Age Specific Population Served:


Pediatric (1 - 12 years)


Adolescent (13 - 17 years)


Adult (18 - 64 years)


Geriatric (65 years & older)


Infant (less than 1 year)


Unit/Department Specific


OSHA Category


Category I - All Employees in this job title have a reasonably anticipated risk of occupational exposure to blood and/or other potentially infectious materials.


POSITION QUALIFICATIONS


Education and Learning:


Required


Registered Nurse


Bachelor's degree in Nursing - preferred


Work Experience:


Required


Minimum of 5 years of experience in nursing


Desired


Care Coordination, Case Management and/or Utilization Management Experience


Ability to or Knowledge of:


Required


Comprehension: understand complex problems and to collaborate and explore alternative solutions


Organization: time management skills, organize and prioritize work schedules of others on short-term basis, organize and monitor multiple projects and files to ensure timely and accurate completion


Reasoning/Decision Making: make decisions which have significant impact on the department's credibility, operations and services, problem solve, demonstrate strong critical thinking and decision-making skills


Communication: demonstrate effective customer service to internal and external customers, express or exchange ideas by means of the spoken word, communicating orally with others, maintain both a high standard of courtesy and cooperation in dealing with coworkers, patients and visitors


Mathematics: add, subtract, multiply, divide, record, balance, and check results for accuracy


Leadership: ability to delegate appropriately and effectively


General - All Positions: demonstrate commitment to quality and attention to detail, be flexible, conceptualize, think abstractly and continuously learn, work as part of a team, anticipate, think and respond quickly, work independently with minimal supervision, complete tasks that require efficiency, organization and a positive attitude under tight deadlines in a high intensity and fast paced work environment, adapt to a changing work environment


General - Patient Care: apply expert professional nursing knowledge, complete clinically-appropriate and timely documentation


Computer Systems/Software/Applications: basic computer skills, knowledge of HER


License and Certifications:


Required


Registered Nurse (RN) licensed to practice in the state of employment


Current American Heart Association (AHA) Healthcare Provider CPR certification


Desired


Certification in Care Coordination or Case Management


PHYSICAL REQUIREMENTS/DEMANDS OF THE POSITION


Sitting: Frequently (34-66% or 5.5 hours)


Static Standing: Continually (67-100% or 8 hours)


Walking/Standing: Continually (67-100% or 8 hours)


Driving: Never (0%)


Stooping/Bending: Occasionally (6-33% or 3 hours)


Squatting: Occasionally (6-33% or 3 hours)


Kneeling/Half Kneel: Occasionally (6-33% or 3 hours)


Climbing Stairs: Occasionally (6-33% or 3 hours)


Climbing Ladder: Never (0%)


Reaching - Shoulder Level: Continually (67-100% or 8 hours)


Reaching - Below Shoulder: Continually (67-100% or 8 hours)


Reaching - Above Shoulder: Occasionally (6-33% or 3 hours)


Repetitive Actions - Fine Manipulation: Frequently (34-66% or 5.5 hours)


Lifting – Other: Occasionally (6-33% or 3 hours)


ENVIRONMENTAL CONDITIONS


Exposed to infectious diseases


If you need assistance with any portion of the application or have questions about the position, please contact the recruiter listed below:


Primary Recruiter:


Recruiter Email Address:


jlelsber@gundersenhealth.org


Equal Opportunity Employer





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