Field IP Concurrent Review Nurse

Responsibilities will include, but are not limited to:

• Identifying inpatient, observation, acute rehabilitation, skilled nursing facility and custodial admissions and discharges by utilizing the following processes:

• •The Plan’s daily census

• •The hospital’s individual Plan admission log (if available)

• •Inquiring Plan admissions/discharges through the admission/ER department offices

• •Direct notification by the member’s PCP or family member

• •Contacting the Plan’s hospitalist program, if available

• Initiates a concurrent review assessment within one working day of admission notification to determine initial and continued length of stay

• Identifies admissions that do not meet the requested level of care (i.e. full admission vs. observation for a hospital facility, inappropriate skill level for a SNF, etc.) and contacts the attending physician to further review and to correct to the appropriate level, if indicated and the attending physician concurs

• Confirms member demographics are correct with the information in the SHP computer system

• •All incorrect information will be documented in the designated area in the system and reported to the SHP Enrollment Department

• Confirms if a Plan member has a health care surrogate identified, in the event he/she is unable to make decisions for himself/herself and documents this information in the SHP system

• Begins identifying discharge planning and transition of care needs, including social needs, for the member with the initial concurrent review

• •Discharge planning and transition of care begins with the admission and should be completely in place prior to the time of discharge

• •Early identification of transition of care needs will help to ensure that the member is discharged to the appropriate level of care setting

• Participates and updates the Plan’s Medical Director, or designee, in completing regular case reviews to ensure the on-going length of stay is appropriate and meets criteria

• Works closely with the attending physician, specialists, the facility case management/social services team, facility ancillary staff, the member and/or legal representative, and the PCP in ensuring lines of communication are open and the immediate and discharge needs of the member are being met

• Identifies, documents in the SHP computer system, any potential coordination of benefits (COB) associated with this member and the admission

• Identifies members who may benefit from care management services and makes appropriate referrals to the Care Management Team, as indicated

• Understands the SHP Care Management Model of Care and actively participates as a member of the Interdisciplinary Care Team, as needed

• Identifies and reports any potential quality or risk management issues to the appropriate Plan designated associate

• Responsible for documenting the following within the authorization in the SHP computer system:

• •Initial review findings, including but not limited to:

• Reason(s) for admission (chief complaint/problem)

• Pertinent medical history, if available

• Prior physical status, if available

• Co-morbidities, if available

• Significant examination, laboratory, and radiological findings

• All major procedures that have been completed or ordered, with findings, if available

• Initial plan of care, including any discharge planning/transition of care needs identified and any identified potential barriers (i.e. member is in a coma and has no legal health care surrogate)

• All communication with the attending physician, consultants and ancillary staff

• Appropriate level of care for the admission meets criteria (i.e. full admission vs observation status, skilled level of care, etc.) and if criteria is not met, interventions completed to correct to the appropriate status

• Approval/denial status and length of stay approved (NOTE: If denied, all required regulatory and Plan P&P’s must be followed)

• •Concurrent review findings, but not limited to:

• Significant changes in the members physical and/or mental status

• Significant examination, laboratory or radiological findings

• Major procedures that have been completed or ordered, with findings, if available

• All communication with the attending physician, consultants and ancillary staff

• Updated plan of care

• Newly identified discharge planning or transition of care needs, including any identified potential barriers

• Approved continued length of stay

• •Upon discharge, the following documentation should be included:

• The members physical and mental status upon discharge

• Any identified physical problems that occurred while in the facility (i.e. ulcerations, falls/fractures, etc.)

• The discharge plan, which should include, but not limited to:

• Discharge disposition (i.e. home, home with HHC, SNF, Acute Rehabilitation Facility, etc.) and the name/address of the facility

• If discharged home, confirmation of the address and phone number that the member or legal guardian can be reached at

• If discharged home with services, documentation of the services (i.e. Nursing, PT, OT, ST, DME) and be specific

• Planned PCP/specialist f/u

• Documentation that Plan discharge information was provided to the member or legal guardian

• All other significant medical information

• •All appropriate diagnoses and procedure codes, including ICD-9 and CPT, must be initially entered and updated, as indicated

• NOTE: For DRG admissions, ICD-9CM coding must be used with ongoing updating of the DRG

• All codes/DRG updates must be confirmed prior to closing a case