Job Posting
Nurse Case Manager/Utilization Review/Swing Bed Coordinator - Nursing
SUMMARY:
The Nurse Case Manager/Utilization Review/Swing Bed Coordinator is responsible for the comprehensive management of patient care, utilizing expertise in case management, utilization review, and Swing Bed coordination. This role ensures the appropriate allocation of resources, optimization of care, and adherence to regulatory and accreditation standards. The Case Manager collaborates with the healthcare team to establish individualized care plans, advocate for patient welfare, and serve as a liaison between patients, families, healthcare providers, and insurance entities. The position requires conducting utilization reviews, ensuring proper documentation, coordinating patient discharge plans, and managing the Swing Bed program for extended care. The role also includes performing duties as assigned by the Chief Nursing Officer (CNO) to ensure the facility's operational efficiency and quality care.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
• Develop, implement, and evaluate individualized care plans for patients.
• Collaborate with the healthcare team to establish treatment plans and monitor patient progress.
• Conduct utilization reviews for patient admissions, ensuring compliance with medical necessity and treatment guidelines (e.g., InterQual). Review and approve patients approaching extended stays (96 hours) for continued care.
• Serve as the Swing Bed Coordinator, ensuring the timely and effective use of Swing Bed services.
• Market and promote the Swing Bed program to the community, targeting potential patients and referral sources.
• Coordinate patient discharge, including arranging for home health services, durable medical equipment (DME), hospice care, and follow-up appointments.
• Submit clinical documentation and information to insurance companies, payers, and transportation services as required. Ensure accurate and timely documentation of patient care and treatment.
• Participate in ongoing quality improvement activities to ensure compliance with healthcare standards, policies, and regulations.
• Resolve conflicts and provide leadership in the absence of the Chief Nursing Officer (CNO) or Assistant CNO, initiating emergency measures when needed.
• Effectively communicate with physicians, charge nurses, staff, department heads, patients, and families. Provide guidance to nursing staff, including LVNs, RNs, and support personnel.
• Participate in department meetings, assist with staff education, and contribute to the development of policies and procedures.
• Ensure compliance with healthcare regulations, including billing accuracy, proper coding (ICD-10 and CPT), and utilization guidelines.
• Perform miscellaneous duties as assigned by the Chief Nursing Officer (CNO), including attendance at required meetings (e.g., Department Head, JRAC, Nursing, etc.).
• Organize and coordinate duties such as orienting new personnel and coordinating intradepartmental services to provide quality patient care.
• Review patient admissions for appropriate admission criteria via InterQual and complete reviews for patients approaching a 96-hour length of admission.
• Arrange for home health, home hospice, DME, etc., as part of the discharge process.
• Submit appropriate clinical information and documentation to payers as needed.
• Oversee and manage Swing Bed services at the facility, ensuring efficient operations and service delivery.
• Take on all responsibilities related to Swing Bed operations.
• Maintain and update required spreadsheets related to patient care and hospital operations.
• Review the previous day's patients to assess ongoing care needs.
• Assist in updating and revising policies and procedures as needed.
• Demonstrate competence in using all relevant nursing and administrative equipment effectively.
• Be willing to float to other units as needed to provide nursing support.
• Provide secondary coverage for infectious control, employee health, and clinical analysis duties when needed.
QUALIFICATIONS:
• Knowledge of case management principles, healthcare regulations, and the utilization review process.
• Strong communication skills with the ability to effectively collaborate with physicians, nursing staff, patients, and families.
• Familiarity with ICD-10 and CPT codes, insurance payers, and healthcare reimbursement processes.
• Ability to analyze and apply clinical data to support decisions regarding the appropriateness of care.
• In-depth understanding of hospital policies, procedures, and patient care standards.
• Ability to maintain confidentiality and adhere to HIPAA standards.
• Proficient in electronic health records (EHR) systems and Microsoft Office.
• Strong organizational skills with attention to detail and the ability to prioritize multiple tasks.
• Commitment to ongoing professional development, including continuing education in Case Management, Utilization Review, and Swing Bed Program coordination.
• Must be able to effectively collaborate with the medical team in establishing treatment plans concerning patient care.
• Must be able to complete client/claimant interaction as needed with various payers, insurance entities, and transportation services.
• Comprehensive knowledge of general nursing theory and practice.
• Personnel Management Principles
• General knowledge of hospital policies and procedures.
• Works closely with Chief Nursing Officer, ACNO, Charge Nurse, Providers, and Staff.
• Ability to communicate with Physicians and fellow workers.
• Competent in clinical skills and use of medical equipment.
• Knowledgeable in the implementation and evaluation of the nursing process and patient care standards.
• Knowledgeable about policies and procedures regarding reporting and release of protected health information (PHI).
• Maintain discretion and confidentiality in communications.
• Proficient in applicable computer software programs.
EDUCATION AND/OR EXPERIENCE:
• Graduate from an accredited school of Nursing. Valid and currently licensed by Texas State Board of Nursing or a compact state as a Licensed Vocational Nurse (LVN) or Registered Nurse (RN) required.
• Bachelor of Science in Nursing (BSN) or Master of Science in Nursing preferred.
• Certification in Case Management (CCM) or Accredited Case Manager (ACM) preferred.
• Current certifications in Basic Life Support (BLS), Advanced Cardiovascular Life Support (ACLS), and Pediatric Advanced Life Support (PALS) required within 180 days of hire. TNCC, ENPC, NRP, and S.T.A.B.L.E preferred. Instructor certifications preferred.
• Maintain ongoing education requirements as stipulated by the Board of Nurse Examiners.
• At least 2 years of experience in case management, utilization review, or Swing Bed program coordination preferred.
• Experience in insurance coordination and patient discharge planning.
• Continuing education in case management, utilization review, and Swing Bed program coordination required.
LANGUAGE/READING SKILLS:
• Communicate verbally and in writing in English.
MATHEMATICAL SKILLS:
• Competent in dosage calculations.
• Basic statistical concepts.
• Proficient in interpreting medical codes (ICD-10, CPT) and understanding reimbursement methodologies.
REASONING ABILITY:
Responds to unusual or varied situations that not covered by existing standards, procedures and precedents. Ability to work under stressful situations and for extended hours, use of proper body mechanics. Mentally alert at all times. Ability to communicate in written form and verbal communication. Ability to respond to unusual or varied situations with sound judgment and within established protocols. Ability to work effectively in high-pressure or emergency situations and manage competing priorities. Strong problem-solving skills and ability to critically assess patient needs and determine appropriate interventions.
WORK ENVIRONMENT:
Ensures the comfort and safety of patients as well as staff. Perform administrative as delegated by Chief Nursing Officer. Ability to adapt to all areas of nursing for staffing needs. Work in a hospital setting with the ability to adapt to various clinical areas based on staffing needs. Ability to ensure the safety, comfort, and well-being of patients while maintaining a sterile, efficient, and compliant environment. Ability to work flexible hours, including weekends, holidays, and on-call shifts if necessary. Requires standing, walking, and the ability to lift or move patients as needed. Ability to perform physical tasks in a hospital environment, including using medical equipment, lifting, and handling medications.
SALARY:
Will be commensurate with Education and Experience.
BENEFITS:
Employer paid Medical insurance with option to add family at a low cost. Dental, Vision and other ancillary insurance available. Amazing retirement with Texas County and District Retirement System, 7% Employee Required Contribution, 225% Employer Match and 8 year Vesting. Accrued PTO and Sick time, and 9 paid Holidays annually.
Additional Information
Position Type : Full Time
Shift : Day
Contact Information
Sonja Mayo - Director of Human Resources
Human Resources
821 Jeffee Dr
Kermit, TX 79745
Email: smayo@wcmh.net
Phone: 4325868215
Fax: 4325868198 |
Rural Health Clinic
In-Patient Services
Swing Bed Services
Physical Therapy
ER Department
Radiology Services
Laboratory Services
Cost of Services