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The Registered Nurse or LCSW Director's responsibilities include developing local care and utilization management systems, monitoring hospital department activities related to discharge planning and clinical quality improvement, and addressing resource utilization matters.
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Supports patient discharge plans prepared and delegated by social work or nurse case management by coordinating with home care agencies, post-acute care facilities, durable medical equipment companies, transportation agencies and others as indicated.
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When naviHealth is delegated for utilization management, review referral requests that cannot be approved for continued stay and are forward to licensed physicians for review and issuance of the NOMNC when appropriate.
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Current working knowledge of discharge planning, utilization management, case management, performance improvement, disease or population management and managed care reimbursement.
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The Utilization Management Coordinator is responsible for all utilization management activities for assigned cases from admission through discharge, including peer reviews and appeals, in accordance with the Utilization Review Plan, for patient population ages 5 years through 21 years, with significant behavioral health needs and Autism Spectrum Disorders or other developmental disorders.
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Evidence of analytic and interpretation skills, with prior experience participating in teams focusing on quality management, utilization management, case management, discharge planning and/or home health or post-acute services (such as inpatient rehabilitation.
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Demonstrates knowledge of utilization review and collaborates with the Utilization Management Specialists to insure the ongoing, comprehensive monitoring and evaluation of patient care, by concurrent and retrospective review to assure appropriate reimbursement.
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This position has primary responsibility for strategic direction; nursing care, acute, observation, SNF, respite care, pediatrics, monitored beds, pharmacy, social services, utilization review, discharge planning, employee health, infection control, risk management and continuous quality improvement.
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Utilization management experience in a medical management review organization, such as Medicare Advantage, managed Medicaid, or Commercial health insurance. The Medical Director conducts Utilization Management of the care received by members in the KY, OH and IN Medicaid market populations.
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Experience in Case Management, Utilization Management, or discharge planning, The Interim Concurrent Review Nurse conducts telephonic concurrent review of inpatient activities and is responsible for ensuring that member care is provided at the appropriate level, for the requisite length of time.
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The Case Manager/RN Navigator is responsible for the comprehensive assessment, planning, implementation, and evaluation of individual patient needs for discharge planning, admission to swing bed and case management including utilization review in accordance with Providence philosophy, objectives, policies, procedures and standards.
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The iCMP Plus APC uses evidence based care approaches, clinical skills, education, and training to influence the clinical outcomes of Medicaid ACO patients by impacting acute care utilization, ensuring optimal treatment for chronic disease management, closing of quality gaps, goals of care conversations and advance care planning.
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Provides clinically based case management, discharge planning, and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care.
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The RN Care Manager is under the general supervision of the Care Management Supervisor or Manager or Director of Nursing and is responsible for patient evaluations of post-hospital needs; development of a transition of care plans and initiation of the implementation of the transitions of care plans prior to the discharge of the patient.
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The RN Care Manager provides education to nurses, physicians and the interdisciplinary team on issues related to utilization of resources, medical necessity, CMS CoP for Discharge Planning and care coordination.
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