JOB SUMMARY

Independently performs tasks guided by policies, clinical guidelines, and procedures.  Selects the best methodology to achieve the outcomes identified in a work plan or project.  Responsible for collecting inpatient data, analyzing and interpreting it, and making recommendations to be used by others at a higher hierarchical level for decision making.

ESSENTIAL FUNCTIONS

• Visits participating hospitals and health centers to determine if records meet established clinical criteria guidelines for admissions and any other required audits, documents relevant recommendations.
• Identifies assigned enrollees from the hospital census and enrolls them in the Inpatient Clinical Program.
• Documents the clinical review of each audit in the electronic system, meeting established quality standards.
• Performs Admission Assessment of all assigned patients during the first 72 working hours of admission to the hospital.
• Primary responsibility will be to provide guidance and support through an individualized plan to all insured persons admitted to the Inpatient Clinical Program with a multidisciplinary team. 
• Ensures that all required services are coordinated on or before 48 hours of discharge in a safe and efficient manner in accordance with evidence-based clinical best practices.  
• Completes discharge assessments for all assigned patients preferably on the same day of discharge or up to 24 hours after discharge and ensures coordination of primary care physician appointment 7 days after discharge. 
• Review of continued stay, proactive discharge planning, transition of care for our patients. 
• Evaluate readmissions to identify same or related diagnosis.  
• Works directly with social worker and discharge planning to ensure coordination of services at discharge.  
• Identifies and refers potential events to various cost containment programs, continuing to follow up on events as appropriate.
• Discusses adverse determination with the company Utilization Review Manager/Supervisor, Medical Advisor, Hospital Coordinator or Treating Physician.
• Notifies the Company Medical Advisor's final decision to the Hospital Coordinator or Treating Physician.  
• Notifies hospital of closed admission events reviewed according to established process. 
• Participates in the weekend scheduling program.

EDUCATION

EXPERIENCE

• Bachelor’s Degree (BD) in Nursing Sciences with one (1) to three (3) years of clinical experience, preferable in hospital environment.
• Current / Active License in Nursing without restrictions in Puerto Rico.  Member of College of Nursing Professionals of PR.

LICENSES AND CERTIFICATIONS

COMPETENCIES