Nurse Inpatient Navigator

Responsible to conduct systematic admission, concurrent, and retrospective hospital reviews for severity of illness and length of stay, to manage an inpatient admission, and to implement discharge planning and make discharge survey calls as required with pertinent clinical information and mandatory data with intervention and follow-up as identified using clinical review algorithm and department standard of operations. and/or Coordinates through performing pre-review requests for long term acute care (LTAC), inpatient rehabilitation, and/or skilled nursing facility using clinical review algorithm as required by line of business, standard operating procedures. and/or Report potential high cost claimants to the appropriate individuals/departments, i.e. stop loss, reinsurance, account executive as required by line of business. and/or Responsible to identify members that may require coordinated care/complex management, disease management, or transition of care services based on clinical risk scores and/or information gathered from review of submitted clinical and submit a referral for review for services as appropriate. Required: Registered Nurse with at least five (5) years' experience. Three (3) of those years may be work experience as a nurse's aide, LPN or other appropriate position in a clinical setting. (RN outside minimum experience may be waived for internal applicants currently employed as an LPN with written recommendation of current supervisor or manager). Preferred critical care or other acute care experience. Active Ohio or WV licensure upon hire. Ohio or West Virginia multistate licensure must be obtained within the 90-day probationary period and maintained throughout employment including compliance with State Boards of Nursing and continuing education policy. Other licensure as company expansion warrants. Demonstration of excellent oral, written, telephonic and interpersonal skills. Demonstration of proficient keyboarding skills and computer literacy with the ability to navigate through multiple systems. Flexibility and demonstration of the ability to balance an independent and team working environment, multitask, work in a fast-paced environment, and adapt to changing processes. Possession of a superior work ethic and a commitment to excellence and accountability. Proven ability to exercise independent and sound judgment in decision making, utilizing all relevant information with proactive identification and resolution of issues. Desired: Utilization Management, Quality Improvement, Case Management, Disease Management, or other Managed Care experience is desirable. Certification in an area of clinical expertise related to current work i.e., CDE, CCM, CMCN, Motivational Interviewing/MI Trainer, etc. Responsibilities: Conducts telephonic and/or on-site admission, concurrent or retrospective review of all inpatient admissions and observation stays. Enters data timely and updates principle/secondary diagnoses and procedures, medical histories, and consults. Investigates missed admissions obtaining pertinent details and refers to the Medical Director as appropriate with completion of documentation and follow up. Determines appropriateness of admission and continued stay using established clinical criteria based on clinical algorithm and standards of operation. Refers admissions/continued stays with questionable medical necessity to the Medical Director with completion of documentation and follow-up. Coordinates care in collaboration with the member, family, health care team members, hospital utilization review, social workers, and other resources to intervene proactively to identify needed medical services, utilization and discharge issues, modifiable risk factors, educational needs, and available resources to affect individual health care outcomes positively. Identifies members requiring discharge planning and facilitates interventions to coordinate care and services. Identifies members that may need chronic disease navigation, complex case navigation, social service intervention and refers appropriately. Acts as a liaison between member, provider, and The Health Plan. Collaborates and shares knowledge and expertise with peers, supervisors, and other staff. Serves as assigned on departmental or company committees and attends departmental or work-group meetings as scheduled. Promotes communication, both internally and externally, to enhance effectiveness of medical management services. Identifies opportunities for improvement in systems, processes, functions, programs, procedures and makes recommendations to the appropriate management staff. Prioritizes assignments appropriately and maintains flexibility as new priorities arise. Identifies potential quality issues, variances, hospital acquired conditions and never events and refers to QI Department. Identifies requests for new technology and communicates that data to the medical policy director. Takes after-hours and weekend call on rotation as assigned (volunteer only). Strives to improve quality in all areas of responsibility and cooperates with all departments to improve quality through The Health Plan Determines appropriateness of pre-authorizations using established clinical criteria and/or guidelines as appropriate per line of business and standard operating procedures. Reviews and evaluates relevant information including member history, medical records, group contracts, benefit design, plan limitations, exclusions, coordination of benefits and member eligibility in making decisions and recommendations that are consistent with sound medical and managed care practice. Facilitates access to care, provides liaison services, advocates for, and educates members as needed. Educates providers when indicated. Promotes communication, both internally and externally, to enhance effectiveness of clinical services. Reinforces appropriate self-care teaching and monitoring and provides up-to-date medical or behavioral health care information to help facilitate the members understanding of his/her options. Identifies and reports potential high-cost cases to the reinsurance or stop loss carrier through hospital review, referral requests, care or complex case navigation or claims cost reports. Provide telephonic guidance and support to members, physicians, and other health care providers to facilitate the best options to meet an individual's health care needs. Contact and engage member participation in the appropriate chronic disease navigation program as appropriate peer line of business. Utilize critical thinking skills to manage and evaluate member status and current treatment regime against evidence-based guidelines. Complete outreach in a timely and effective manner according to protocols and adjust frequency and types of contacts to meet program goals per standard of operations. Demonstrate a working knowledge and adherence to contractual guidelines and policies of The Health Plan. Achieve optimal clinical and quality outcomes by effectively managing care and resources. Participate in quality improvement activities to achieve program outcomes.

Created: 2024-10-29