Under the direction of the Medical Director and in coordination with the quality improvement activities, the Quality Utilization Nurse is responsible for review and evaluation of clinical services provided to PACE participants. The nurse will primarily focus on initial and concurrent reviews of in-patient hospitalization, using Interqual criteria to determine admission appropriateness, anticipated length of stay and potential discharge needs. They appropriately and expeditiously refer cases to the Medical Director, process Medical Director decisions in the electronic medical record and notify the hospitals of determinations. The nurse may also refer cases with quality of care concerns to the Medical Director and Quality Improvement Director and assist with quality improvement functions as needed. This can include conducting periodic audits of PACE program processes related to clinical program requirements.
