Utilization Nurse

BASIC FUNCTION:

Incumbent is responsible for providing professional nursing care to, and performing case management duties for, patients of the Seneca Nation Health System (SNHS) in accordance with established standards and practices, within the bounds of training and professional licensure. 

GENERAL RESPONSIBILITIES:

Monitors primary care patients admitted to acute care hospitals, including tracking admission status, diagnosis, length of stay, and anticipated discharge needs.

Serves as the clinical liaison between the primary care team, hospital case management, attending providers, and ancillary services to ensure continuity of care during inpatient stays.

Reviews hospital treatment plans and utilization of services for medical necessity, appropriateness, and alignment with payer, regulatory, and organizational guidelines including PRC authorization requirements.

Conducts post-discharge follow-up, including timely outreach to patients and caregivers to assess clinical status, medication reconciliation, follow-up appointments, and adherence to discharge instructions.

Identifies gaps in care, potential readmission risks, and social determinants of health impacting recovery; escalates concerns to the primary care provider or care team as appropriate.

Tracks and monitors patients admitted to skilled nursing facilities (SNF), including admission reason, anticipated length of stay, progress toward discharge goals, and barriers to return to the community.

Coordinates with SNF nursing staff, social workers, and therapy teams to ensure care plans are consistent with primary care goals and discharge planning expectations.

Reviews and documents utilization metrics, including hospital admissions, readmissions, emergency department use, and SNF utilization.

Supports transitions of care by ensuring timely scheduling of primary care follow-up appointments and specialty referrals following discharge from hospitals or SNFs.

Ensures accurate, timely documentation in the electronic health record and utilization management systems in compliance with regulatory, accreditation, and payer requirements.

Participates in interdisciplinary care team meetings to discuss high-risk patients, complex cases, and opportunities for utilization improvement.

Educates patients and families on care plans, available resources, and expectations during transitions across care settings.

Applies evidence-based guidelines, utilization review criteria, and organizational policies to promote cost-effective, high-quality care.

Contributes to quality improvement initiatives aimed at reducing avoidable admissions, readmissions, and inappropriate SNF utilization.

Assesses the patient’s formal and informal support systems including caregiver resources/involvement as well as available benefits/community resources, making referrals where appropriate.

Provides direct patient care and assists with examinations/procedures as needed. Performs any/all nursing duties required to provide adequate patient care.

Assists patients with treatment adherence and medication compliance. Monitors status changes and reports concerns or changes to the provider.

Provides culturally sensitive care for patients of all ages. Responsible to handle appropriately any/all communications necessary for patient care, both incoming and outgoing.

Records all information necessary for patient care accurately, and ensures timely entry of all required data into the electronic health record. Generates reports as needed.

Maintains a safe, comfortable, and therapeutic environment for patients and families in accordance with SNHS standards.

Promotes a cooperative and cohesive workplace environment to maintain high quality services to patients.

Participates and promotes Patient Centered Medical Home (PCMH) guidelines and procedures. Responsible for any/all electronic health record functions and duties required for patient care.

Documents all patient contacts according to the provisions of the Privacy Act of 1974.

Enhances professional growth and development through participation in educational programs, review of current literature, and various workshops as available.

Assists with monitoring adherence to departmental processes.

Ensures confidentiality of records according to the provisions of the Privacy Act of 1974 and HIPAA.

Upholds and promotes the value and integrity of the Seneca Nation Health System’s mission statement. Will promote SNHS in a positive manner.

Provides care through a trauma-informed lens by incorporating key principles of both physical and psychological environment safety, trustworthiness and transparency, collaboration of decision-making during treatment plan developments, empowerment of patients by recognizing and building upon individual strengths, as well as recognizing and respecting the diversity of cultural backgrounds and sensitivity.

Attends all mandatory staff meetings, trainings and in-services.

Follows all department, SNHS, and Seneca Nation policies.

KNOWLEDGE, SKILLS, & ABILITIES:

Excellent communication, interpersonal and patient service skills.

Good analytical and problem-solving skills.

Ability to stand for long periods of time.

Excellent computer skills.

QUALIFICATIONS:

Current NYS licensure as Registered Professional Nurse.

Minimum of 3 years’ clinical experience providing direct patient care as an RN.

Case management and/or utilization review experience and certification preferred.

Basic Life Support (CPR and AED) certification, or the ability to obtain certification within six months of hire. Responsible to maintain up-to-date certification.

Experience in a large hospital, academic medical center, outpatient health care setting, or Indian Health Service (IHS)/tribal health, preferred.

All required licenses, certifications, and credentials must be obtained prior to hire and maintained throughout employment at the employee’s expense, unless otherwise specified.