To us, it’s about living life to the fullest while serving our
patients, teammates, neighbors and friends. We are dedicated and
passionate in everything we do, seeking challenge and appreciating
the routes that got us here. Whether our path is clinical or not,
we all came to find balance and meaning in our lives within the
work we are passionate about and the adventures we live.
Maximizes reimbursement for both patient and hospital through
cooperation with third party payers and physicians. Follows up on
denials based on resource utilization issues. Provides a smooth
transition for the patient from hospital to home or alternative
care setting through coordination of services to meet the post
discharge needs identified while maintaining a balance among
quality outcome, cost, and process. Identifies those patients with
significant psychosocial needs and makes referrals to Social
Services. Promotes continuous quality improvement by monitoring
team processes as well as through communication with other teams
impacted by or impacting the processes of this team.
ESSENTIAL JOB FUNCTIONS:
Monitors for appropriateness of admission, continued stay, and
readiness for discharge based on department defined guidelines and
criteria as evidenced by appropriate documentation. Demonstrates
utilization review accuracy using Interqual criteria.
Informs the patient and the attending physician when the patient
doesn’t meet acute care criteria according to department
Cooperates with other departments in defense of denial of
services by reviewing the chart for documentation of
appropriateness of the admission/continued stay as evidenced by
provision of supporting chart documentation.
Communicates with attending physicians when necessary.
Identifies the post-hospital equipment and unmet care needs of
the inpatient and The Medicare patient (including observation)
beginning within 24 hours of notification of admission as evidenced
by placement of the completed discharge planning needs assessment
form in the social service section of the chart.
Identifies the psychosocial needs of the patient and/or family
and addresses those needs or make a referral to social services as
appropriate as evidenced by documentation on the discharge planning
needs assessment form.
Identifies the unmet financial needs of the patient and
addresses those needs or make a referral to Inpatient Admissions
Representative for HELP program or Social Services as
Ensures that no services are denied for lack of clinical
information when accurate contact numbers are received from
Insurance Verification within the payer’s time-frame as evidenced
by absence of denials which fall within the above guidelines.
Follows-up with patients within 14 days post-discharge where
discharge planning referrals were made to identify the adequacy /
flaws in the process.
Role models the principals of a Just Culture.
Perform other duties as assigned. Must be HIPAA compliant.
One year recent experience in acute care hospital Utilization
Review, Discharge Planning or equivalent.
Two years experience in case management if incumbent is a
Licensed Practical Nurse (LPN).
Licensed as a Registered Nurse in the state of Colorado or from
a valid compact state OR licensed as a Licensed Practical Nurse in
the state of Colorado required
Computer / Typing:
Must possess, or be able to obtain within 90 days, the computers
skills necessary to complete online learning requirements for
job-specific competencies, access online forms and policies,
complete online benefits enrollment, etc.
Must have working knowledge of the English language, including
reading, writing, and speaking English.
Associates or Bachelor's degree in nursing.
Able to pass annual inter-rater reliability competency exam
(IRR) with a score of 80%.
Vail Health, formerly Vail Valley Medical Center, is a nonprofit
community health care system serving patients and guests from
around the world. Locally operated and governed by a volunteer
board of directors, Vail Health includes a 56-bed hospital,
accredited by the Joint Commission. Our 24/7 emergency department
in Vail is a Level III Trauma Center with a nearby helipad for
necessary medical transports.
Vail Health provides a wide array of services and access points
including Beaver Creek Medical Center, urgent care clinics in Avon
and Gypsum, our Edwards medical campus, Eagle Healthcare Center and
a multispecialty clinic in Frisco. Howard Head Sports Medicine
offers physical therapy services at 10 locations and works closely
with our internationally renowned orthopaedic partners at The
Steadman Clinic and Vail-Summit Orthopaedics. In addition, Vail
Health's Shaw Cancer Center and Sonnenalp Breast Center are the
region’s only fully accredited cancer treatment center and
comprehensive breast center.
The Vail Clinic, which was founded in 1965, officially became
“Vail Valley Medical Center” in 1980, its first year as a
full-service hospital. At that time, we had one primary location
and 25 physicians. Today, Vail Health has locations in nine towns,
nearly 1,000 employees, 260 physician partners and 85