Bergen Regional Medical Center CLINICAL DOCUMENT REVIEWER in United States
The role of the Clinical Documentation Reviewer involves identifying immediate and ongoing needs of the patient and planning a course of care, including measurable goals and/or objectives, with the patient, providers, family, caregivers and payers. The CDR compares the plan to evidenced-based guidelines, approved clinical pathways or protocols and other standards of care to determine variances from expected outcomes. When variances exist, the CDR works with physicians and appropriate multidisciplinary personnel to suggest possible solutions and adjustments. He or she is responsible for monitoring quality measures, processes and outcomes to promote high-quality, cost effective care record to support admission or level of care decisions.
Initiates a case management plan and discharge planning activities at time of the first admission review, and updates it based on patient’s progress and needs.
In consultation with a patient’s physician, establishes a targeted discharge date at time of the admission review. Documents and communicates this targeted discharge date to the patient’s family, nursing and the multidisciplinary team via established processes.
Uses clinical knowledge and defined standards of care to proactively identify inappropriate resource consumption and discusses with attending physician. Refer appropriate cases to physician advisor for review, as appropriate.
Understand third party payers and current BRMC contractual agreements. Completes and communicates admission and concurrent review information to 3rd party payors. Document all payer contact and denial.
Documents and transmits appropriate patient-level information to other unit-based case managers and/or discharge planners to ensure timely and accurate continuation of case management services when patient is transferred within the hospital.
Monitors daily progress, including vital signs, resolution of signs and symptoms related to a procedure, complications, medications, fluids, pain
Meets with family/patient and communicates plan of care at time of assessment, and as appropriate throughout admission. Documents interaction and plan of care in medical record.
Initiates referrals to appropriate departments and services within and outside the hospital.
Serves as a liaison between the hospital and other facilities, home health and community agencies, and makes arrangements as needed for equipment and other required items to be available at the time of discharge.
Monitors patient’s progress against BRMC-approved medical necessity guidelines, and evidence-based pathways/protocols. Identifies variances from standards or guidelines of care, and actively engages physician for decision making and intervention.
Collects variance and delay data at time of occurrence (e.g., avoidable days, delays) for use by the department and organization.
Provides notice of termination of benefits and level of care changes to individual patients and/or representative and other applicable parties on a timely basis.
Uses data and information on a daily basis to prioritize and drive work effort.
Leads multi-disciplinary rounds on a daily basis. Works to ensure that all department are accountable in coordinating efforts to achieve timely and appropriate patient care.
Assumes responsibility for continuing education/professional development related to area of practice. Obtains continuing education in relevant topics as necessary for professional growth.
Participates in department and hospital Performance/Quality Improvement activities, as assigned.
Keeps statistics and records as required.
Assumes additional responsibilities as delegated by the Director of the Department.
Current NJ licensure as RN required. BSN or Bachelor’s degree in related field preferred. Minimum 2years general clinical hospital experience required.
Certification in Case Management (CCM) preferred upon hire or to be obtained within one year of hire.
Three to five years of Utilization Review or Case Management experience preferred in acute care settings.
Previous InterQual experience preferred.
Behavior health experience with knowledge of emergency room admission criteria desirable.
Must have current experience in behavioral health with knowledge of emergency room admissioncriteria.
Experience in a long term care setting and working knowledge of Medicare Skilled Nursing Programand Medicare requirements desirable.
.Ability to lead multi-disciplinary planning and decision making sessions.
Critical thinking/problem solving skills.
Expertise with medical and multi disciplinary practices and/or standards of care for selected diagnosis or conditions.
Good interpersonal skills.
Requisition Number: 16-0915
Post Date: 11/21/2016
Title: CLINICAL DOCUMENT REVIEWER
Employee Type: Full Time Day
Work Hours: 40.0