Perform and document clinical reviews to determine medical necessity, using InterQual, and physician determination of length of stay (LOS).
Collaborate with admitting provider, obtain and enter appropriate patient status orders in the EMR (i.e., inpatient, outpatient, or observation)
Perform concurrent utilization review as assigned following contractual obligations
Denials and Appeals Management
Observation Management: Review observation cases every four (4) hours to assess for possible conversion to Inpatient or stability for discharge.
Maintains accurate transfer and divert log
Supports EMTALA compliance
Maintain current knowledge of and follow Medicare and Medicaid requirements
Proactively identifying, documenting, and escalating problems with over/under utilization of hospital resources
Documents avoidable days as appropriate
Collaborates effectively with departmental staff to achieve goals and objectives
Utilizes internal or external Physician Advisor as needed to resolve level of care discrepancies
Each employee is responsible for implementing SJRMC's Service Standards into their daily work:
Safety, Courtesy, Effectiveness, and Stewardship
Other duties as assigned
Physical Demands and Environmental Work Conditions:
Physical:
Minimum physical effort required
Intermittent sitting with freedom of movement
Minimal walking bending, lifting, pulling, and reaching
Mental:
Fast paced environment, numerous interruptions, numerous phone calls
Frequent periods of concentration with attention to details with frequent opportunity for diversification of tasks
Ability to shift tasks to adjust to patient needs in a timely manner
Work performed in a modern, well-equipped environment
Interfaces with fellow employees, patients, and guests of hospital daily
Able to use various office equipment, including expertise in computer programs in performance of routine duties.
Benefits
Health insurance
Additional Information
Creating Life Better Here starts with you. At San Juan Regional Medical Center, we're more than a healthcare provider-we're a values-driven organization dedicated to delivering exceptional care. As a team member, you help fulfill our mission to make life better here for our community.
The Clinical Access Case Manager (CACM) supports efficient patient flow and capacity management through timely placement of patients from all portals of entry including the emergency department, transferring facilities and procedural areas. CACMs provide a coordinated approach with the providers and Managing Resource Nurse (MRN) to determine appropriateness of admission and the appropriate status. Assures robust utilization review and appeals process.
Required Behaviors :
As you go about fulfilling this mission, your work habits and work relationships should embody SJRMC's values. These values are our culture, our identity as an organization. Sacred Trust, Personal Reverence, Thoughtful Anticipation, Team Accountability and Creative Vitality ask more of us than merely completing some list of tasks. Our values ask for a deeper level of commitment, and what is asked of us we freely give because we believe in our mission.
Required Qualifications :
Current RN license in the state of New Mexico
Minimum of three (3) years' experience in acute care required
Assertive and diplomatic communication skills
Self-motivated and accountable
Team Oriented
Sjrmc · San Juan Regional Medical Center