Case Manager​/Utilization Review RN - Sacred Peaks; DH

Overview

Navajo Preference Employment Act

In accordance with Navajo Nation and federal law, TCRHCC has implemented an Affirmative Action Plan pursuant to the Navajo Preference in Employment Act. Pursuant to this Plan and corresponding TCRHCC Policy, applicants who meet the necessary qualifications for this position and (1) are enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe will be given preference in hiring and employment for this position, (2) are legally married to enrolled members of the Navajo Nation, Hopi Tribe, or San Juan Southern Paiute Tribe and meet residency requirements will be given secondary preference, and (3) are enrolled members of other federally-recognized American Indian Tribes will be given tertiary preference.

POSITION SUMMARY

Incumbent serves as an Outpatient/Inpatient Case Manager/Utilization Review Registered Nurse (CM/UR RN) for TCRHCC and is responsible for direct supervision and supportive contact for the specific group of identified patient assignments and high-risk patients. The CM/UR RN is responsible for designing and managing a continuum of care focusing on empowering clients to achieve demonstrable outcomes and self-sufficiency. The CM/UR RN is responsible for assessment, service planning, and resource acquisition, monitoring progress and initiating and responding to emerging client needs.

The CM/UR RN performs Utilization Review and Management/Clinical Documentation Chart Reviews of patients in the acute clinical care setting, ambulatory care setting and will conduct UR reviews as required. The CM/UR RN will work closely with the Social Work (MSW) Case Manager on Discharge Planning and Care Transitions. The CM/UR RN will work closely with the Physician Advisor and participate on the UR Committee as well as conduct Clinical Documentation Chart Reviews related to peer review, financial or insurance determination, or claims denials.

The CM/UR RN will link the client with Community Social Service providers, health care providers, substance abuse, and mental health providers to achieve specific goals. The CM/UR RN will have experience working with culturally diverse low-income populations having multiple barriers to self-sufficiency such as: illiteracy, welfare dependency, domestic violence, substance abuse, and mental health issues. The CM/UR RN will work with a multidisciplinary team within the service delivery setting.

The CM/UR RN will be committed to Case Management Services and have some collaboration with Purchased and Referred Care (PRC) formally known as Contract Health Services, providing assistance with the PRC Case Specialist. The CM/UR RN reports to the Director of Care Coordination.

The CM/UR is responsible for compliance with CMS Conditions of Participation regarding Utilization Review and Discharge Planning including implementation and annual review of the Utilization Management Plan and assisting with the coordination of the Utilization Management Committee. The CM/UR is also responsible for ensuring compliance with the Joint Commission and Federal and state regulatory bodies, provisions of care regarding discharge planning and patient needs for care, treatment, and services after discharge or transfer are met.

The CM/UR follows the hospital's Case Management/Utilization Program that integrates the functions of utilization review, discharge planning, and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated resources. The hospital’s case management model outlines a collaborative practice to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes

NECESSARY QUALIFICATIONS

Education:

Associates Degree in Nursing, must obtain bachelor’s in nursing within two (2) years of hire

License/Certification:

• A valid, current, full and unrestricted Professional Nursing License to practice as a Registered Nurse (RN) in any state of the United States of America, The Commonwealth of Puerto Rico, or a territory of the United States
• Must have and maintain…