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Transitions of Care Nurse

Company: Commonwealth Care Alliance
Location: Springfield
Posted on: May 18, 2019

Job Description:

OVERVIEW

Commonwealth Care Alliance s (CCA) Transitions of Care Unit is responsible for the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, under the provisions of CCA s benefits plan.
The Transitions of Care Inpatient Utilization Management (UM) Review Nurse is responsible for day-to-day timely clinical and service authorization review for medical necessity and decision-making. The Utilization Management Review Nurse has a key role in ensuring CCA meets CMS compliance standards in the area of service decisions and organizational determinations for members in inpatient acute care hospitals, Long Term Acute Care hospitals, and Acute Rehab Hospitals.



RESPONSIBILITIES

* On-site presence and telephonic coverage at assigned hospitals, skilled nursing facilities and long term care facilities where there are CCA members admitted.
* Utilizes clinical criteria including Interqual to determine level of care decisions
* Authorizes and makes service decisions based on member s needs including requests for rehab or referral to outside specialists. Utilizes CCA resources, clinical decision support tools and the primary care team to help inform decision-making.
* Works collaboratively with attending MD, NP at facility and CCA Transitions of Care Unit to determine and communicate appropriate level of care.
* Works with facility staff to identify and coordinate care plans and discharge plans
* Oversees care provided in assigned facility. Addresses concerns as they arise. Detects/reports quality of care concerns. Participates in resolution and recommends process improvements.
* Facilitates communication between facility team, member, family and primary care team as needed.
* Actively participates in care planning meetings; family meetings; discharge planning.
* Demonstrates a comprehensive understanding of chronic disease management and preventive health maintenance. Obtains data as needed. Keeps medical records up to date with member s information. Documents encounters within 48 hours.
* For Long Term Care patients, performs comprehensive assessments every 6 months or with significant change in condition.
* For all patients, promotes principles of empowerment, self-efficacy and independence.
* Other nursing duties as assigned.
* Makes home visits within 48 hours to members discharged from facilities as needed.

QUALIFICATIONS

Minimum Education required: Bachelor's Degree in Nursing
Licensed RN in the Commonwealth of Massachusetts
Minimum Years Experience required:
5 years of related work experience

Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.

Keywords: Commonwealth Care Alliance, Springfield , Transitions of Care Nurse, Healthcare , Springfield, Massachusetts

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