RN- Pre Admission/Throughput
Department: 7510-NURSING ADMINSTRATION
Location: Doctors Hospital at Renaissance
Type of Position: Full-Time
•Under the general supervision of the Resource Management Director and collaboration with the Chief Nursing Officer, the RN Throughput acts as a patient advocate to hospital clients. Performs pre-admission screening review of patients using Severity of Illness/Intensity of Service (IS/SI) Criteria InterQual or Milliman) to determine appropriateness of admission, level of service (inpatient, observation, outpatient) and appropriate location of services to be provided (critical care, acute, step down unit, etc.) Intervenes with medical staff to obtain additional documentation to support IS/SI as appropriate. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients not meeting admission criteria, to facilitate achievement of quality and cost efficient patient outcomes. The RN Throughput identifies opportunities to reduce cost while ensuring the highest quality of care is maintained by collaboration with unit based case managers and social workers, to reduce admission diversions and emergency room holds. Review criteria is applied to determine medical necessity for admission. The RN Throughput provides coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care by:
•coordination with physicians’ offices to assess appropriateness of direct admissions to include clarification of admission orders regarding status, level of care and diagnosis
•liaison between nursing and physicians during transfers into the facility; assessing the medical appropriateness of the transfer as well as the financial implications
•assists Bed Board and House Supervisors with patient flow to assure patients are placed as quickly as possible, thereby reducing emergency holds and necessity of diversion
•during hours of down time, assists case management with retro reviews and/or floating to areas of increased activity and high census
The RN Throughput works collaboratively with interdisciplinary staff internal and external to the organization, and participates in quality improvement as directed by Director of Resource Management. The RN Throughput is on-site and available seven days a week, as well as holidays and, therefore, is required to work a weekend rotation and an occasional holiday and will required to be on call.
Assists in the development and implementation of the preadmission flow through program.
Collaborates with other members of Resource Management, encourage appropriate resource utilization.
Works with nurse managers and other clinical departments in program development.
Provides orientation and ongoing education specific to flow through and direct admit process.
Provides follow-up to system issues and reports individual practitioner variances appropriately to PA or Department Director.
2.Directs and coordinates new admissions utilizing the Patient Flow Through process.
a.Monitors the effectiveness of the Patient Flow Through program.
b.Participates in case finding and preadmission evaluation screening to ensure reimbursement.
c.Works with attending physician and care team members to move patient through the hospital system and set up appropriate services or referrals.
d.Performs pre-admission screening review of Direct Admission patients using InterQual or Milliman Criteria to determine appropriateness of admission, level of care (Inpatient,
Observation, Outpatient) and appropriate location of services to be provided. (Critical Care, Telemetry,
e.Upon identification of discrepancy /failure to meet inpatient or observation criteria, notifies appropriate physician for intervention, and/or correction ; when appropriate, notifies the physician advisor and/or EHR.
f.Assures physician orders match face sheet.
g.Serves as a liaison to any third party payer case managers for admission and status determination.
a.Documents delay in service variances as per policy; captures data relating to the admission of those patients that did not meet status, but were admitted.
b.Recognizes and immediately intervenes in cases of suspected abuse or neglect.
c.Recognizes National Patient Safety Goals and Core Measures as applicable to the patient populations served.
3.Plays an essential role in assisting physicians, nurses, and staff with an accurate determination of a patient’s observation status.
a.Consults with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient.
Accurately applies InterQual or Milliman criteria 95% of the time in determining status. Refers appropriately to the PA when medical decision making determination is necessary.
4.Reviews admissions to determine the medical necessity for admission, using pre-established criteria.
Contacts the attending physician to notify him or her of the decision to issue notice of pre-admission non-coverage. Explains UR process and insurance coverage requirements. Obtains physician’s written concurrence when necessary.
Refers cases not meeting criteria appropriately, following contract requirements for all other payers. Refers when appropriate to the physician advisor and to EHR.
5.Collaborates with Quality Management Department: Performs quality assessment reviews and studies as requested by the Director of Resource Management, TJC standards, and third-party payer regulations.
Refers all potential quality of care issues identified, not reviewed, as part of the quality assessment screening to the physician advisor to facilitate timely follow up.
Refers quality issues to the Resource Management Director, PA or Chief Compliance Officer.
6.Interacts, communicates, and intervenes with multidisciplinary healthcare team in a purposeful, goal-directed fashion. Works proactively to maximize the effectiveness of resource utilization.
Anticipates, initiates, and facilitates problem resolution around issues of resource use.
a.Establishes a means of communicating and collaborating with physicians, other team members, the patient’s payers, and administrators.
b.Utilizes appropriate resources in cases that present ethical dilemmas.
c.Communicates to appropriate members of healthcare team the patients at risk of losing insurance coverage or HINN notification of Medicare and Medicaid patients.
d.Maintains a proactive role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement.
e.Reviews physician documentation and, when needed, follows procedures to seek clarification of documentation relative to diagnosis and comment, on the patient’s clinical state.
•An RN license, BSN preferred or Bachelors degree in healthcare related field is required.
•Current license/valid permit to practice in the State of Texas will be required of all certified individuals.
•Certification in Case Management (CCM) is highly desired.
•Candidate must demonstrate proficiency in both the English and Spanish language.
•Knowledge in the areas of case management and utilization management, experience with Managed Care and utilization management as it relates to third-party payers preferred.
•Five years clinical experience is required, with experience in a Hospital or acute care setting being strongly preferred
•Experience in use of InterQual and or Milliman criteria and review processes highly desirable.
•Knowledge and understanding of Medicare and Medicaid guidelines and regulations pertaining to utilization review and discharge planning .