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Essential Functions:

1. Plan, develop, organize, implement, evaluate, and directs the Utilization Review/Discharge Planning Department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that conform to current standards of practice and operational policies while maintaining compliance with state and federal laws and regulations.
2. Develop, maintain, and periodically update writing policies and procedures the day-to-day functions of the utilization review/discharge planning department.
3. Develop, maintain, and periodically update utilization review/discharge planning procedures.
4. Communicates and interprets policies and procedures to hospital staff, and monitors staff practices and implementation.
5. Evaluates the work performance of all utilization review/discharge planning personnel and implements discipline according to policies and procedures.
6. Coordinates utilization review/discharge planning services with all other departments.
7. Collaborates with physicians, community agencies and institutions to improve the quality of services and to resolve identified problems.
8. Oversees utilization review/discharge planning schedule to ensure the department meets regulatory and budgetary standards.
9. Participates in the recruitment and selection of utilization review/discharge planning personnel and ensures sufficient staff are hired.
10. Oversees and supervises development and delivery of in-service education to equip utilization review/discharge planning staff with sufficient knowledge and skills to provide compassionate, quality care for patients.
11. Proactively develops positive employee relations; promotes teamwork, mutual respect, and effective communications.
12. Monitors staff for compliance with facility polices on workplace safety.
13. Monitors the infection control program designed to provide a safe, sanitary, and comfortable environment designed to prevent the transmission of disease and infection.
14. Coordinates and/or develops on-going quality assurance activities for hospital to monitor compliance with standards and regulatory requirements through rounds, interviews, and record reviews.
15. Participates in budget development for the utilization review/discharge planning department.
16. Helps prepare staff for inspection surveys, instructing staff on matters of conduct and disclosure, being interviewed by inspectors, immediate corrections of problems noted by surveyors. Reviews and reinforces important standards previously cited.
17. Participates in the preparation of the Plan or Correction response to an inspection survey, and implements any follow-up required for any utilization review/discharge planning allegations.
18. Communicates directly with patients, families, medical staff, hospital staff, interdisciplinary team members, and department heads to coordinate care and services.
19. Promotes customer service and hospitality and responds to and adequately resolves complains or concerns from patients or families about utilization review/discharge planning services.
20. Promotes compliance with accident prevention procedures, safety rules, and safe work practices to prevent employee injury and illness and control workers’ compensation costs.
21. Assures staff is trained in fire and disaster and other emergency procedures and evaluates performance during drills.
22. Ensures proper testing by qualified personnel for equipment efficiency.
23. Provides for effective admission certification and continued stay reviews for inpatient, long-term, observation, and outpatient surgical admissions.
24. Monitors current patient census and length of stay to ensure Critical Access Hospital utilization limits are observes.
25. Reviews all inpatient, long-term, observation, and outpatient surgical admissions to ensure all admissions criteria and length of stay criterial have been properly met and documented.
26. Ensure positive interaction with attending physician to resolve any issues with admission criteria.
27. Contacts, furnishes information to, and receives approvals from peer review organizations and third party payers in accordance with current laws and regulations.
28. Assess the patients’ home situation relative to discharge planning.
29. Recommend and assist in placement of patient in nursing home:
    • Arrange transportation as necessary.
    • Inform and interpret Medicare, Medicaid, welfare, and community resources.
    • Use community resources to supplement and reinforce discharge planning activities.
    • Recommends patients in need of financial assistance to Financial Counselor.
30. Counsels and involves patient and/or family in the discharge planning, acceptance of illness, advance directives, and treatment processes.
31. Obtain necessary physician orders for referrals.
32. Reviews discharge plans for patients on a daily basis.
33. Collects, analyzes, and maintains data on the utilization of medical services and resources.
34. Report activities and statistics to department directors as needed.
35. Obtains pre-approval and pre-certification from third party payers for procedures and continued stay.
36. Supervises and acts as back up for the Swing Bed Coordinator position.
37. Perform admission, readmission, and continued stay reviews for all inpatient and observation cases; utilizing the InterQual criteria to support compliance with regulation as well as track delays and reasons to ensure process improvement.
38. Participate in wide variety of special projects and compile a variety of special reports.

Required Education and Experience:

1. Minimum Associates degree in nursing.
2. Current, valid certification in the state of Georgia as Registered Nurse.
3. Current, valid AHA Healthcare Provider training (BCLS and ACLS).
4. Experience in management in hospital environment including working knowledge of utilization review/discharge planning requirements.

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