Case Manager RN

Position Summary

Monitors the admissions, continued stay, and discharge of patients following pre-established criteria. Assures that patients meet MCG criteria from admission to discharge including appropriateness of level of care. Conducts interdisciplinary care management rounds. Ensures collaboration between multidisciplinary healthcare team members, primary physician, community agencies, HMOs/PPOs, CCS, etc., whose services may be required and/or related to the care needs of the patient after hospital discharge. Monitors nursing and medical plans of care/discharge plans and provides appropriate interventions to assure care is appropriate, coordinated and that avoidable patient days are addressed effectively through education, consultation, and counseling as needed. Ensure patient centered discharge planning and assessment by communicating the appropriate discharge information and instructions to the primary care giver and primary physician and/or follow-up care agency. Assures patients are transferred to appropriate approved facilities when required.

This position requires providing service to medical/surgical, telemetry, critical care, and the geriatric patient population in a manner that demonstrates an understanding of the functional/developmental age of the individual served.

Case Management is a collaborative practice model including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The Case Management process encompasses excellent communication, both verbal and written, and facilitates cases along a continuum through effective resource coordination. The goal of the Case Manager is to advocate for and assist the patient in the achievement of optimal health, access to care and appropriately utilizing resources. The Case Manager utilizes the following processes to meet the patient’s individual healthcare needs: assessment, planning, implementation, coordination, monitoring and evaluation of the plan of care.

 SPECIFIC JOB DUTIES:

• Discharge planning with the patient, family, and discharge support person within two working days of admission.
• Completes the initial case management assessment/preliminary plan and documents in the electronic medical record
• Performs admission and continued stay review by utilizing criteria approved by medical staff to ensure that patients meet Severity of Illness/Intensity of Service criteria per departmental protocol.
• Confers with the attending/consulting physician(s) as appropriate when the medical necessity for admission or continued stay is not clear.
• Consults with the Physician Advisor when the admission or continued stay does not meet criteria, care is not being provided timely or does not meet the community standard of care.
• Provides clinical review information to external review entities or insurance companies to ensure authorization for admission and continued stay is obtained.
• Obtains authorization from payer and documents in the EMR per established protocol.
• Accurately completes the MediCal Treatment Authorization Request (TAR) in detail to ensure payment for hospital services.
• Refers medically complex patients to the insurance’s complex case management program as appropriate.
• Facilitates transfer of patients to other acute care facilities as required either due to third party payer requirements or for higher level of care.
• Identifies potentially avoidable days, delays in service, over utilization or quality of care issues and completes reports as required.
• Refers appropriate patients to Social Services for psychosocial assessment/intervention.
• Monitors progression of care, documents barriers, and modifies care plan as appropriate.
• Accurately documents the case management process in the electronic medical record.
• Provides Freedom of Choice per policy and completes the PASRR for all SNF transfers prior to discharge as required.
• Collaborates with the Inter-disciplinary team members in discharge planning activities on an ongoing basis.
• Actively prepares and participates in Interdisciplinary Care rounds/conferences to facilitate coordination of care, goal setting, and develop strategies to facilitate the discharge planning process and resolve barriers.
• Communicates the final discharge date and plan with the patient and family to ensure that they are informed as required by law and documents such notification in the electronic medical record.
• Provides accurate information and completes referrals as appropriate to implement the discharge plan including but not limited to Home Health Services, Hospice, Skilled Nursing Facilities, Durable Medical Supplies, and other community resources.
• Maintain confidentiality as required by HIPAA and only provides information relating to payment, hospital operations or continuity of care.
• Provides “hand off” information to the receiving Case Manager to ensure safe, smooth transitions.
• Follows Medicare regulatory requirements as it relates to patient appeals (IM Letters, HINN letters), and Condition Code 44.
• Refers situations requiring immediate intervention to the Director of Case Management, Risk Management, Director of Quality Management, and Physician Advisor.
• Participates in committee meetings, patient care conferences, and other activities as assigned.
• Participates in department Performance Improvement activities.
• Participates in orientation of new employees or cross training other Case Managers as needed.
• Maintains accurate records and statistics of case management activities, documents all interventions related to case management in EMR.
• Demonstrates a continuing effort to improve the quality of case management performance through on-going education.
• Incorporates the core values; dignity, collaboration, justice, stewardship and excellence into daily performance.
• Performs other related duties as assigned or requested.

Minimum Qualifications

• Valid RN License
• Valid BLS Card
• Valid MAB Certificate preferred
• Four years of recent acute care experience in a critical care setting (preferred)
• Two years of Utilization Management/Case Management experience in an acute care setting
• Bedside work experience preferred
• Working knowledge of Interqual or MCG, and Intensity of Service/Severity of Illness criteria.
• Working knowledge of Title XXII and Title XIX.
• Working knowledge of reimbursement related to Medicare, Medi-Cal, Capitation, and Managed Care.
• Ability to negotiate orders with the physicians in order to assign alternate levels of care.
• Working knowledge of community resources.
• Working knowledge of methods to resolve patient needs such as discharge planning, Home Health, Durable Medical Equipment and Skilled Nursing Facilities.
• Ability to case manage smoothly and increase patient/physician satisfaction while staying within guidelines.
• Ability to track outcomes and report findings.
• Able to problem solve effectively.
• Ability to use clinical knowledge to identify potential quality issues, delays in service, post-acute care needs required.
• Must have excellent oral and written communication, interpersonal, problem-solving, conflict resolution, presentation, time management, and positive personal influence and negotiation skills.
• Must have strong clinical assessment and critical thinking skills necessary to provide utilization review/discharge planning services appropriate to patients with complex medical, emotional and social needs.
• Must have the ability to work in a high volume caseload environment and deal effectively with rapidly changing priorities.