Clinical Nurse III, Acute Inpatient Behavioral Health Utilization Management

Summary

SUMMARY :  Under general direction, works in collaboration with treatment team and other disciplines to assure the appropriate admit status and medical necessity for admission, concurrent, and discharges, securing the appropriate documentation and planning for continuing care. Identifies care issues and conveys barriers to discharge to appropriate disciplines while intervening to assure progression in the treatment planning. Follows AHS (Alameda Health System) and Behavioral Health Department Alameda County Utilization Review Plan to obtain authorization of acute inpatient services. Provides medical necessity and patient Care related documentation to non Medi-Cal payor sources. Documents authorization status and patient care related significant details in EHR. All tasks can be completed virtually and with minimal supervision.

DUTIES & ESSENTIAL JOB FUNCTIONS :   NOTE : The following are the duties performed by employees in this classification. However, employees may perform other duties at an equivalent level. Not all duties listed are necessarily performed by each individual in the classification.

1. Assures clinical interventions are appropriate for the admitting diagnosis and reflect the standard of care, as defined by The Joint Commission (TJC), Centers for Medicare and Medicaid Services, and AHS and Behavioral Health Department of Alameda County Utilization Plan.

2. Collaborates with the treatment team; reviews all inpatient admissions for appropriate admit status based on medical necessity criteria of Medi-Cal and / or commercial insurances and ensures the patient is registered at the appropriate level of care.

3. Communicates with treatment team members to provide the continuity of care while supporting and maintaining the treatment team approach to ensure effective resource utilization.

4. Actively participates in treatment team meeting to discuss discharge planning.

5.  During the initial review, screens for discharge needs and makes the appropriate recommendations to ensure a safe transition to a post-acute level of care.

6. Initiates authorization and follow up process with Behavioral Health Department of Alameda County and AHS Admissions / Eligibility / Enrollment services for uninsured patients.

7. Works with patient care team and vendors to procure DME (Durable Medical Equipment) .

8. Notifies denials to the attending MD and treatment team members via EHR.

9. Reviews patient Account notes in EHR as needed for account updates and insurance accuracy.

10.  Completes the DHCS PASSR for patients being referred to a SNF or Morton Bakar Center.

11.  Independently processes the denial Work Ques and Patient Account Work Ques in EHR.

12. Identifies and escalates the complex cases at the appropriate level and coordinates case conferences as needed.

13.  Actively participates in the quarterly URC meeting and discusses trends, patterns, and problem cases.

14.  Identifies high utilization risk patients and notifies the treatment team.

15.  Communicates with the treatment team via Care management report and Likely no medical necessity report daily.

16.  Documents medical necessity and patient care related information in the identified fields in EHR.

17.  Maintains current knowledge of clinical practice and Utilization Management by literature review, membership in a professional organization.

18.  Maintains continuing education related to specialty or pursuing certification.

19.  Makes appropriate referrals to homecare specialists or social work when clinically indicated.

20. Monitors ongoing patient care and makes suggestions to achieve optimal outcomes, based on vidence based best practice.

21.  Participates in outcome data monitoring and audits as needed.

22.  Performs concurrent reviews assigning acute, administrative and denied days as per ACBH concurrent review policy.

23. Utilizes clinical knowledge and defined standards of care to proactively identify inappropriate resource consumption and reports as appropriate.

MINIMUM QUALIFICATIONS :

Education : Graduate of an accredited Nursing Program required; Bachelor's degree in Nursing preferred.

Minimum Experience : Previous Behavioral Health Utilization Management or Care Management experience in inpatient acute

setting required.

Minimum Experience : Two to five years recent clinical experience in acute inpatient behavioral health setting required.

Required Licenses / Certifications : BLS - Basic Life Support Certification issued by the American Heart Association.

Required Licenses / Certifications : TEAM training Techniques for Effective Aggression Management (required for all positions at John George Psychiatric Pavilion; and certain positions in the Emergency Department).

Required Licenses / Certifications : Valid license to practice as a Registered Nurse in the State of California.\

Pay Range $89.32- $131.08

The pay range for this position reflects the base pay scale for the role at Alameda Health System. Final compensation will be determined based on several factors, including but not limited to a candidate’s experience, education, skills, licensure and certifications, departmental equity, applicable collective bargaining agreements, and the operational needs of the organization. Alameda Health System also offers eligible positions a generous comprehensive benefits program.

John George Psychiatric Hospital

JGP Care Coordination

Services As Needed / Per Diem

Day

Nursing

FTE : 0.01