RN - UTILIZATION MANAGEMENT

Legal Entity

Aultman Hospital

Position Summary

The RN - Utilization Management for Aultman Hospital will promote appropriate allocation of healthcare/hospital resources while maintaining high quality patient care through concurrent and retrospective reviews of the medical necessity of inpatient admission and outpatient observations. Reviews take into consideration severity of illness, intensity of services, length of stay, level of care and discharge plan.

Department Summary

Utilization Management department oversees the process of evaluating and monitoring the medical necessity, appropriateness, and efficiency of treatments, procedures, and services provided to hospitalized patients.

Qualifications

• Graduate of an accredited school of nursing; BSN preferred.

• Current, active licensure as a Registered Nurse through the Ohio Board of Nursing.

• Obtain and maintain current American Heart Association (AHA) training in Basic Life Support (BLS) utilizing Resuscitation Quality Improvement (RQI) is required.

• Certification preferred for RNs meeting applicable certification eligibility requirements.

• Membership in professional nursing organization preferred.

Department Qualifications

• Five years' experience in the acute care setting.

• Certification in UR, Case Management, Quality or related field preferred.

• Knowledge of Managed Care concepts in relation to financial aspects of patient care.

Skills

• Proficient computer skills to complete tasks as required.

• Must be organized, able to effectively prioritize tasks and exhibit appropriate time management skills.

• Must be detail oriented while focusing on safe practices and quality care.

• Demonstrates effective communication.

• Effective appropriate and professional interactions with colleagues/physicians, patients and visitors.

Department Skills

• Receive, understand, and implement direction from supervision and management.

• Effectively function within the framework of department and organizational policies and procedures.

• Adaptability to changing work environment or needs.

• Knowledge of Managed Care concepts in relation to financial aspects of patient care.

• Able to cope with the emotional and mental stress of the position and deadlines imposed on specific duties.

• Demonstrate critical thinking skills, problem-solving abilities and an understanding of systems and process change process.

• Function autonomously, displaying personal integrity and always maintaining confidentiality.

• Able to work with all levels of the multidisciplinary healthcare team.

• Refined negotiating skills and the ability to deal with conflict resolution.

• Functions in the role as patient/family advocate intervening as needs indicate.

• Dresses in professional manner, wearing either lab coat or jacket when in the clinical setting.

Responsibilities & Expectations

• Respects patients' rights and responsibilities.

• Is courteous in dealing with all customers, whether external or internal.

• Demonstrates compassion and sensitivity to all customers.

• Shows respect for the customer's culture, language customs and beliefs.

• Maintains high standards of ethical and professional behavior.

• Actively participates in quality improvement activities within the department.

• Utilizes available educational resources to maintain and develop knowledge and skills related to field of practice.

• Demonstrates competency in application of InterQual.

• Works closely with ED providers and actively oversees assignment of Observation status and manages status issues related to this service.

• Oversees patient's clinical progress to assure appropriate use of resources and timely care delivery.

• Provides information to meet external payer requirements to ensure hospital reimbursement.

• Identifies and participates in the development and implementation of strategies to reduce unnecessary resource consumption and length of stay on assigned patient population.

• Monitors delays in care and discharge, actively intervening as appropriate to eliminate delays and provide timely access to care and services.

• Collaborates with medical staff and other members of the healthcare team to ensure effective, efficient delivery of care and services.

• Communicates, both verbal and written, post-hospital care needs and plan to all members of the healthcare team.

• Functions as a resource to medical staff and hospital staff regarding regulatory and payer requirements.

• Communicates concerns to other areas within the hospital as appropriate (Performance Improvement, Infection Control, Risk Management).

• Functions as a team member, working closely with Social Workers, RN Case Manager, precertification/verification specialists to promote positive patient outcomes.

• Identifies opportunities for inter and intradepartmental operational improvements.

• Provides coverage for team members as needed.

• Participate in regular meeting forums.

• Other duties as assigned.

Working Conditions

• Meal and break times are coordinated with other staff members to maintain adequate coverage.

• Shifts are scheduled or changed due to the staffing needs of the unit/department based upon volume and acuity.

• Work weekends and holidays as assigned or as applicable based on department needs.

• Cross training depending upon department needs.

• Work 8-12 hours per day, adjusting hours to meet unit and customer needs.

• This unit requires daily coverage, 7 days per week.

• Hybrid/WFH schedule may be available based on staffing and the needs of the unit.

• Subject to frequent interruptions during performance of duties.

• Must be able to utilize computer/word processing.

Hazardous Exposure Category

Category III - Includes tasks that involve no exposure to blood, body fluids, or tissues and Category I tasks are not a condition of employment. The normal work routine involves no exposure to blood; body fluids or tissues (although situations can be imagined or hypothesized under which anyone anywhere might encounter potential exposure to body fluids.) Persons who perform these duties are not called upon as part of their employment to perform or assist in emergency care or first aid or to be potentially exposed in some other way.

Physical Addendum

Demands

Frequency

Remarks

Lifting 0-10 lbs

Occasional 10-33%

Lifting 10-20 lbs

Occasional 10-33%

Lifting 20-35 lbs

Occasional 10-33%

Lifting 35-50 lbs

Occasional 10-33%

Lifting 50-75 lbs

Never

Lifting 75-100 lbs

Never

Lifting over 100 lbs

Never

Forward Reaching

Frequent 34-65%

Overhead Reaching

Frequent 34-65%

Standing

Occasional 10-33%

Walking

Occasional 10-33%

Sitting

Frequent 34-65%

Climbing

Never

Stairs/Ladder

Occasional 10-33%

Bending/Stooping

Occasional 10-33%

Twisting/Turning

Occasional 10-33%

Kneeling/Squatting

Occasional 10-33%

Crawling

Never

Pushing/Pulling 0-10 lbs

Frequent 34-65%

Pushing/Pulling 10-20 lbs

Occasional 10-33%

Pushing/Pulling 20-35 lbs

Occasional 10-33%

Pushing/Pulling 35-50 lbs

Occasional 10-33%

Pushing/Pulling 50-100 lbs

Never

Pushing/Pulling over 100 lbs

Never

Carrying 0-10 lbs

Occasional 10-33%

Carrying 10-20 lbs

Occasional 10-33%

Carrying 20-35 lbs

Occasional 10-33%

Carrying 35-50 lbs

Occasional 10-33%

Carrying 50-100 lbs

Never

Carrying over 100 lbs

Never

Grasping/repetitive sustained

Frequent 34-65%

Fine motor coordination

Continuous 66% of the day

Vision: Near/Far/Color

Continuous 66% of the day

Hearing: ordinary conversation/other

Continuous 66% of the day

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender identity, sexual orientation or protected veteran status. The organization is an EEO/AA Employer M/F/Disability/Vet.

The organization will provide reasonable accommodations to employees or applicants with disabilities, as defined by the Americans with Disabilities Act, who are otherwise qualified to safely perform the essential functions of the job, with or without accommodation, unless such accommodation would constitute an undue hardship on the organization or poses a direct threat to the health and safety of the individual or others that cannot be sufficiently mitigated by reasonable accommodation. Any applicant or employee who requires an accommodation to perform the essential functions of his or her job or to enjoy equal benefits and privileges of employment should notify the Aultman Human Resource Department and request such an accommodation.