Coordinates systems and services with an organized, inter/trans-disciplinary team approach which delivers quality, cost-efficient care to patients through the continuum of health care services. Appropriateness of admission and continued stay reviews are conducted concurrently or retrospectively. Collaborates with the patient, family and other members of the health care delivery team to facilitate appropriate movement through the care continuum as demonstrated through quality outcomes. Works effectively with internal and external customers and proactively improves case management processes. Provides direct input to St. Anthony Hospital annual Utilization Management/Case
Management/Performance Improvement Plans and is accountable for the successful completion of the action plan developed. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient care givers, and Health Information Management coding staff to ensure the clinical documentation reflects the level of service rendered to patients and is complete and accurate.
Facilitate appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record. To access medical necessity and coordinate with Unit CM.
Update DRG worksheet to reflect any changes in patient status, procedures/treatments, and confers with the physician to finalize diagnoses. Conduct follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been recorded in the patient's chart. Conduct follow up reviews of clinical documentation to ensure points of clarification with the physician have been recorded in the patient medical record.
Review clinical issues with the coding staff to assign a working DRG. Refer all issues to coder, CDS working committee for resolution and policy adaptation. Assess needs and communicates the plan, evaluates effectiveness, and revises the plan as needed to reflect changing needs, outcomes, age, and developmental status.
Establish working DRG, and length of stay information and documents in HBOC ELOS. Communicate any instance of lack of medical necessity that is not documented and or lack of need for continued stay will be discussed with the CM, physician, Medical Advisor(s), and department management as indicated.
Develop strong bonds with Medical Staff, Advanced Practitioners, and physician office practices to facilitate program implementation. Flex hours to meet the needs of the program to have one-on-one time with the physicians to explain and promote program as needed, refer all unanswered queries and patterns of disagreement to Medical Advisor for resolution.
Stay current with, and conduct ongoing utilization review, changes in payer requirements, and clinical documentation management program education for new and existing staff, including clinical documentation specialist, physicians, and nursing and allied health professionals.
Complete all worksheets and track and remove from discharge area in software program at least 60 days after pt. discharges from the hospital.
Facilitate appropriate clinical documentation to ensure that the level of services and acuity of care are accurately reflected in the medical record and takes step to clarify if documentation not available. Improve overall quality and completeness of clinical documentation.
Assist in screening process by documenting working DRG utilizing and optimizing all strategies from CDMP education and the software program. Collect, record and maintain clinical information gathered from concurrent or retrospective review of the medical record and compares to approved standards, pathways or protocols. Refer to Medical Advisors all outstanding MR with no response for review. Monitor patterns and refer to UR Committee for corrective action.
Participate actively in improvement within the CM, SW and Bed Assignments departments. Serve as a resource and hospital liaison to patients/families, physicians, the health care team and external organizations with regard to the case management program, available health care resources, appropriate level of care and financial issues. Review all short stay MR that has not received a CDS review related to LOS and work patterns.
Foster, participate and is knowledgeable in Shared Accountability as defined at St. Anthony; supports and participates in the work of depart-based council. Demonstrate responsibility and accountability for own practice, continuing education, competency and quality. Participate in committees, teams, councils and work groups. Perform other related duties as assigned that correspond to the overall function of this position.
Qualifications Minimum Qualifications:
Licensed by the Oklahoma Board of Nursing as a Registered Nurse.
Five years of recent clinical experience in health care as a registered nurse with demonstrated management experience and leadership ability.
Current CPR (Healthcare Provider).
Two years Utilization Review/Utilization Management or Case Management preferred.
Knowledge of computer software and hardware applications and basic statistics preferred.
About SSM St. Anthony's Hospital
St. Anthony Hospital is a 601-bed regional referral facility specializing in cardiology, oncology, surgery and behavioral medicine. The hospital, established in 1898, is located in Midtown Oklahoma City and serves the needs of Central Oklahoma, as well as many counties throughout Oklahoma, through its large rural affiliate network of hospitals. Four St. Anthony Healthplex campuses provide convenient emergency and outpatient service access to the outlying communities of the metropolitan area. St. Anthony added urgent care services in May 2015 at St. Anthony North. St. Anthony has received numerous awards including the Oklahoma Quality Award for Excellence, Certified Healthy Business, Premier QUEST® Award for High-value Healthcare Citation of Merit, among others. Healthsights ranks St. Anthony at performance levels for quality and patient satisfaction higher than local competitors and many national health care organizations.
You’ve known us as many names throughout St. Louis, and now, we’re bringing our hospitals, doctors, home care and other services together under one name – SSM Health. With seven hospitals, 350+ physicians, more than 40 physician locations and 12,000 employees, we are part of something bigger and better. We’re connected to a wealth of resources, expertise and advance technology to help you, your fa...mily and our community live long, healthy lives.
We’ve grown and changed a lot over our 143-year history. Our name may be changing but our mission remains the same