Presbyterian Healthcare Services

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at Presbyterian Healthcare Services

Posted: 3/6/2020
Job Reference #: 8747
Keywords: medical

Job Description

Requisition ID
Case/Utilization Mgmt/Care Coor
Location : Name
Presbyterian Espanola Hospital
Default: Location : City
Default: Location : State/Province (Full Name)
New Mexico


Known as “The Jewel of Northern New Mexico,” Española sits at 5,500 feet above sea level and is a cultural destination. With a population of more than 10,000, Española offers a community environment that is growing, yet rooted in its southwest culture. Learn more about Española:

Job Description
Type of Opportunity: Part Time (.45 to .89)
FTE: 0.800000
Exempt: Yes
Work Schedule: Days

Manages the use of resources from admission to discharge transition during an episode of illness for patients of all ages. Works closely with the patients, patients families, nurses, patients service representative, and the patient s doctor to coordinate an episode of care from the perspective of resource utilization, utilization review, quality outcomes and smooth transition to other services in the community such as home care, SNF, long-term care, or community coordinators.


*Manages the care of patients, which includes coordinating the development, implementation, monitoring, and modifying an individual s plan of care through an interdisciplinary and collaborative team process. This involves working with the individual, family, physician, payer, and caregivers from various providers to achieve mutually agreed upon outcomes.

*Makes round to nursing units for the purpose of data collection, case review, and monitoring of patient s condition daily. Discharge planning is initiated on admission or as soon as possible. Identifies high risk patients by population and assures that a referral upon discharge has been made for all high risk patients. Documents all changes on discharge planning on patients chart which becomes part of the patients permanent record. Follows up with all patients discharged home within seven days of discharge and documents follow-up.

*Provides the Director of Nursing with a report of changes and recommendations pertaining to Case Management. Performs studies according to requirements per Espanola Hospital as relate to QA and PH Oryx initiative. Communicates any Quality of Care issues with the QA coordinator.

*Monitors practices and procedures to ensure staff are implementing the recommended guidelines and that timely reporting is done. Manages resources. Maintains expertise on benefits, reimbursement, and contract/regulation changes of managed care, Medicare, Medicaid, and commercial payers to allow optimization of reimbursement on a case-by-case basis and assist physicians in determining appropriate level of care settings. Performs concurrent and retrospective utilization review functions per established internal and external guidelines. Evaluates the financial and clinical benefit of care coordination to the patient, providers, and payers.

*Prepares summaries of special investigations or reviews on the outcomes of case management interventions. Prepares monthly summary of study findings and reports to the Quality Assurance Department at Espanola Hospital. Makes recommendations to the Director of Nursing, as necessary, concerning the Case Management program.

*Assists the Quality Assurance Committee in evaluating and revising quality assurance practices and implements policies and procedures to ensure continuous quality care is maintained.

*Orients new employees to the importance of case management policies and procedures as well as the employee s responsibility in following procedures. Meets with staff to assist in identifying and correcting problem areas and/or the improvement of services as necessary. Assist department directors in developing, implementing, and conducting inservice training programs. Effectively communicates with and assists other members of the nursing team and/or other disciplines. Actively participates in problem-solving and conflict resolution to maintain team cohesiveness.

*Coordinates, documents, and communicates transition planning for individuals in collaboration with the patient, family, physician, members of the interdisciplinary team and payers regarding progress on plan of care and transition team. Utilizes Critical pathways and educational protocols to facilitate seamless delivery of care across the continuum towards optimal wellness. Maintains a working knowledge of and relationships with community resources. Educates individuals, staff, and community on wellness, health promotion, and self-care opportunities.

*Manages/performs the intake/referral process to assure appropriate level of care in coordination of services to be provided. Assures that the supporting physician orders and documentation accompanies the individual across the continuum of care. Communicate with payers and providers to assure reimbursement and appropriate level of care.

*Research relative to appropriate utilization of in/out patient resources, is current complete, and always available. Forms for tracking patient utilization of resources, evaluating service provided by community agencies/resources, etc. are developed, utilized and revised so that appropriate information can be obtained, tracked, trended. Reassesses patients periodically to assure that services are appropriate, cost-effective, and not increasing the patient s dependence. Evaluates patient outcomes.

*Supports and maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental and infection control standards. Role models professional growth and development through participating in educational programs, current literature, inservice meetings and workshops. Participates and maintains awareness of ongoing self-management activities and assists with the implementation of changes as recommended by the committees. Assists in orientation of new staff of students and serves as a resource person and professional role model. Professionally responsible for current nursing research, current protocols and procedures, hospital philosophy, and hospital programs in order to maintain quality. Plans the unit budget.

*Performs other functions as required.<B


Other information:
Bachelors degree in nursing. Valid and current NM Registered Nurse license required. Three to five years acute care experience. Previous experience in managed care environment and some knowledge of current ICD-9 CM and CPT-4 coding practices and conventions are desirable. Must be familiar with reimbursement issues. Must have strong verbal and written communication skills and proficiency in problem solving, critical analysis, and clinical assessment. Strong interpersonal skills are necessary. Must have ability to work in a stressful environment and to set priorities and organize work to accomplish diverse tasks under time constraints, to make independent decisions, and to demonstrate accountability for actions.

* Bachelor Degree

Education specialization:
* Nursing

* Registered Nurse-NM


Benefits are effective day-one (for .45 FTE and above) and include:

  • Competitive salaries
  • Full medical, dental and vision insurance
  • Flexible spending accounts (FSAs)
  • Free wellness programs
  • Paid time off (PTO)
  • Retirement plans, including matching employer contributions
  • Continuing education and career development opportunities
  • Life insurance and short/long term disability programs

About Us
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.

Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.

We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.

Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.

New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses. </

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