Case Manager Utilization RN

2 weeks ago

Toronto, Ontario, Canada HealthEcareers - Client Full time
Job Summary:

As a Utilization Review Nurse with HealthEcareers - Client, you will work collaboratively with physicians to coordinate and screen for the appropriateness of admissions and continued stays. Your expertise will be utilized to make recommendations for alternate levels of care when patients do not meet the medical necessity for inpatient hospitalization. You will interact with patients, families, and other disciplines to coordinate safe and acceptable discharge plans, functioning as an indirect caregiver, patient advocate, and manager of patients in the most cost-effective way without compromising quality. You will also be responsible for complying with AB 1203, Post Stabilization notification, and other duties as described.

Essential Responsibilities:
  • Develop and implement individualized plans of care to ensure continuity, quality, and appropriate resource use.
  • Collaborate with physicians and other healthcare professionals to recommend alternative levels of care and ensure compliance with federal, state, and local requirements.
  • Assess high-risk patients in need of post-hospital care planning and develop discharge plans to meet their identified needs.
  • Review, monitor, evaluate, and coordinate patients' hospital stays to ensure timely and efficient delivery of essential services.
  • Participate in bed huddles and implement recommendations congruent with patients' needs.
  • Coordinate the interdisciplinary approach to providing continuity of care, including utilization management, transfer coordination, discharge planning, and obtaining authorizations/approvals as needed for outside services.
  • Conduct daily clinical reviews for utilization/quality management activities based on guidelines/standards for patients in various settings.
  • Act as a liaison between in-patient facilities and referral agencies, providing case management to patients referred.
  • Refer patients to community resources to meet post-hospital needs and coordinate transfers to appropriate facilities.
  • Adhere to internal and external regulatory and accreditation requirements and compliance guidelines.
  • Educate healthcare team members about their roles and responsibilities in the discharge planning process and appropriate resource utilization.
  • Provide patients with education to assist with their discharge and help them cope with psychological problems related to acute and chronic illness.
  • Report any incidence of unusual occurrences related to quality, risk, and/or patient safety.
  • Review, analyze, and identify utilization patterns and trends, problems, or inappropriate utilization of resources.
  • Coordinate, participate in, or facilitate care planning rounds and patient family conferences as needed.
Basic Qualifications:
  • Two (2) years combined RN experience in an acute care setting or case management required.
Additional Requirements:
  • Demonstrated ability to utilize/apply the general and specialized principles, practices, techniques, and methods of utilization review/management, discharge planning, or case management.
  • Working knowledge of regulatory requirements and accreditation standards.
  • Demonstrated ability to utilize written and verbal communication, interpersonal, critical thinking, and problem-solving skills.
  • Demonstrated ability in planning, organizing, conflict resolution, and negotiating skills.
  • Computer literacy skills required.
Preferred Qualifications:
  • Bachelor's degree in nursing or healthcare-related field.

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