Ld Case Manager

Position Details

Department: PCH-EV JV | Case Management

Location: Gilbert

Shift: Mon-Fri, Days, 8am-5pm

Category: Care Mgmt/Social Wrk/Case Mgr

Posting #: 1069911

Employee Type: Full-Time

Position Summary

The position provides comprehensive care coordination for patients as assigned and assesses the patient's plan of care. Develops, implements, monitors and documents the utilization of resources and progress of the patient through their care, advocating and facilitating options and services to meet the patient's health care needs. Assists the Manager, Case Management with the daily operational activities by monitoring quality and effectiveness of workflow, problem resolution and troubleshooting issues, and processes to ensure optimum efficiency and compliance with all regulatory and licensing requirements. This position may supervise Case Management staff on an ad hoc basis as directed to do so by the Manager of Case Management. This position works independently receiving supervision of work activities from the Manager of Case Management or designee.

Position Duties

• Leadership

Provides guidance, mentoring, and direction as appropriate for ongoing staff development.

Rotates on-call responsibilities with other assigned staff.

With the Medical Director of Utilization Management and the Care Management leadership team plans, recommends and implements approved protocols, policies, and guidelines and supports overall organizational values and mission.

Participates in hospital and departmental operational initiatives to evaluate and improve reimbursement, denials, level of care, goal length of stay and improve delivery care methods.

Functions as part of a leadership team with the Lead CM, Manager of CM and Director of CM on operational changes, quality improvement and or productivity issue for the Care Management Department

Coordinates work activities of assigned staff to ensure achievement of established goals, objectives, and outcomes.

Leads employees through ongoing goal setting, training and performance feedback.

Evaluates performance of case managers and assists in completing performance appraisals.

Provides team leadership, demonstrates strong, consistent clear communication and serves as central point of information informing all team members.

Keeps families and patients involved and informed as demonstrated by feedback.

Cultivates and maintains effective interaction/communication with members of the interdisciplinary care team and families to drive the care coordination process and to facilitate continuity of patient care.

• Coordination of care

Manages a defined service line patient population to achieve optimal discharge and continuity of care outcomes in a manner that promotes sound financial stewardship and patient-family advocacy.

Completes an initial screen of all patients on admission (not to exceed within 24 hours of admission) utilizing MCG criteria to identify needs related to care coordination and/or discharge planning.

Leveraging MCG and other evidence-based guidelines, coordinates, development and implementation of a comprehensive discharge care plan in collaboration with the clinical care team.

Ensures plan of care is in place with all team members. Proactively collaborates with members of the interdisciplinary clinical care team to define and document a clear and comprehensive treatment plan, including post-discharge needs. Identifies and facilitates resolution of variances in the plan of care that may impact length of stay. Facilitates referral to other disciplines, and monitor for appropriate follow-up.

Facilitates and provides on-going communication with patient/family and escalates unresolved barriers to timely discharge to Case Management, Manager or Utilization Management Medical Director, as per department protocols.

Reviews and analyzes third-party payer denials for in house patients and communicates to attending physician, Case Management, Manager, Utilization Management Medical Director and Utilization Management Nurse as per department protocols.

Cultivates and maintains effective interaction/communication with members of the interdisciplinary team. and proactively engages patient and families in the care coordination across the continuum of care.

Reviews the patient daily for appropriate patient status and goal length of stay per the established Case Management prioritization protocol and per MCG criteria and communicates goal length of stay to clinical care team and patient and family.

Keeps patient discharge information current in Case Manager EMR documentation. Assesses each patient's status and activities daily as appropriate to patient needs. Ensures timeliness of care and identifies barriers to transition of care or discharge.

Participates in interdisciplinary rounds or service line rounds with clinical care team.

• Develops collaborative health care team

Collaborates with clinical care team partners on level of care, goal length of stay, identified barriers, and other issues that may impact reimbursement.

Establishes a collaborative relationship with the interdisciplinary team , hospital revenue cycle management and staff, and community providers. Mentors internal members of the health care team on utilization management and managed care concepts .

Identifies from review of documentation, opportunities for increased education with physicians and the health care team.

This position performs onsite job duties and responsibilities at Phoenix Children''s, and is viewed as an accessible member of the health care team.

Participates in weekly department process improvement meetings.

• Regulatory Responsibilities

Reviews the patient daily (Observation and Inpatient) for appropriate status and meeting admission or discharge criteria.

Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct ongoing care planning and discharge planning.

Utilizes MCG criteria/guidelines/paths to determine admission status, level of care, goal length of stay and continued provision of services as evidenced by audit of documentation in EMR.

Documents avoidable days, extended length of stay, authorizations and denials for medical necessity in EMR and financial applications as evidenced by audit.

Communicates to Utilization Management Nurse data supporting denial appeals, or notification of potential denials.

Communicates with payers to resolve potential denials.

Obtains and reviews necessary medical reports and subsequent treatment plan

requests to conduct ongoing insurance reviews.

Manages a defined service line patient population to achieve optimal outcomes in the

most cost-effective manner.

Working knowledge of DRG payment methodology and ICD-9/10 coding system.

Provides Medicare/Tricare Rights and Detailed Notice of Discharge to patient and families.

• Transition and discharge planning

Assures thorough, early and ongoing transition/discharge plans by collaborating with patients, families, payers and providers across the continuum of care.

Assesses patient for appropriate discharge placement. Identifies presumed discharge location on admission.

Consults with social services and other resources as needs or problems are identified.

Communicates transition/discharge plans and problems to other case managers as care is transitioned. Ensures that health care team is proactive in making arrangements for transition/discharge, and ensures that each transition/discharge plan has clear goals that are attainable. Ensures that all elements of patients'' needs are addressed in the transition/discharge plans.

Validates that family and patient are aware and understand discharge plan as demonstrated by documentation and feedback.

Ensures that education and teaching for family and patient to support transition/discharge is begun as quickly as possible with the health care team.

When appropriate, performs outpatient and clinic care coordination and monitors patients care as they transition between inpatient and outpatient service.

• Provides excellent customer service

Establishes a collaborative relationship with interdisciplinary team, community providers and Hospital Revenue Cycle management and staff.

Provides excellent service routinely in interactions with all customers, i.e. coworkers, patients, visitors, physicians, volunteers, etc.

Responds to emails within 24 hours.

Clear communication skills with all internal and external customers.

• Performs miscellaneous job related duties as requested.