Hours: Per Diem
Shift: 8-hour Day shift. Min 4 per month including weekend and holiday.
The Case Manager provides clinically-based case management (CM) to support the delivery of effective and efficient patient care. Has the overall accountability for the utilization management, care coordination and discharge planning for the patients within the assigned caseload. Collaborates with other members of the health care team to identify appropriate utilization of resources and to ensure maximum reimbursement. Utilizes criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources.
PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:
Job duties specific to this position:
- Introduces self to the patient/family, explains CM, and provides patient with contact information.
- Completes an initial screen of all patients within 24 hours of admission utilizing specific criteria to identify needs related to utilization management.
- Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria and third party information.
- Appropriately uses Interqual criteria for leveling of care.
- Ensures appropriate level of care documentation by the physician.
- Conducts concurrent admission and continued stay reviews based on appropriate utilization criteria, established standards, procedures and policies.
- Documents authorization numbers, days approved data, and denial data as outlined in the departmental policy and procedures
- Assess the needs for a Medicare IM, delivers admission notice if not already done so by admitting.
- On a daily basis, identifies cases that fail to meet criteria and promptly reviews the case with the patient’s physician to resolve the issue.
- Elevates complex cases to the Director of CM and/or the PA advisor appropriately
- Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.
- Proactively follows and intervenes on open cases to include concurrent appeals of denials.
- Retrospectively addresses denials by reviewing the patient record and case management worksheets. Writes the letter of appeal for pertinent denials.
- Contacts the attending physician to notify him/her of all decisions to issue a notice of non-coverage for all payers.
- Informs the patient and/or next of kin when third party benefits must be terminated. Issues the termination letter following established hospital policy.
- Identifies trends related to reimbursement and communicates to the Director.
- Educates staff and physicians about managed care principles, observation status, discharge planning, reimbursement rules and range of patient care setting beyond observation, intensive care and acute hospitals.
- Collaborates with members of the multidisciplinary team to facilitate the case management and care coordination processes for the assigned caseload.
- Facilitate care coordination rounds.
- Participate in complex care/extended stay rounds with the PA advisor.
- Refers appropriate cases to social work (SW) based on established referral criteria and professional judgment.
- Consults with medical staff as needed to facilitate accurate documentation and to assure an appropriate timely discharge.
- Monitors patient progress and plan of care with the aid of internal and external utilization guidelines.
- Makes every attempt to prevent readmissions.
- Facilitates a patient-specific, safe discharge plan to the appropriate setting.
- Assesses the patient/family for care needs during hospitalization to establish an effective discharge plan in collaboration with the patient and the multidisciplinary team.
- Identifies potential barriers to discharge or transfer and communicates them to the care team to spearhead resolution of the issues where possible.
- Delivers second IM notice to Medicare recipients if appropriate, facilitating appeal if needed.
- Reports issues and system barriers to efficient and effective discharge planning to the Director.
- Communicates with or makes referral to the patient’s Outpatient CM.
- Make follow up phone calls to the patients regarding the understanding of and compliance with the discharge plan.
- Contributes in a positive manner to the development of the CM department.
- Communicates information in a clear and timely manner.
- Although the CM assignments are unit based, each case manager is expected to cross cover other areas as needed and requested.
- Documents in the patient record according to department policies and procedures.
- Seeks and provides peer consultation about cases that are presenting problems and/or experiencing significant deviation from the plan of care.
- Participates in quality improvement and evaluation processes related to the CM practice.
- Participates in the development of procedures, roles, systems and structures related to the CM practice.
- Interacts with patients, families, colleagues and external contacts with respect, sensitivity and attentiveness to promote teamwork and cooperation.
- Adheres to CM department specific and organizational policies and standards such as as TJC, Dept of Health, etc.
- Participates in activities of professional associations as appropriate.
- Participates and assists in departmental studies and projects as assigned.
- CMs are on site and available seven days a week as well as holidays. Therefore, CMs are required to work weekend end rotations and holidays are scheduled.
Job duties for all positions:
- Takes responsibility for ensuring that all work outcomes satisfy the HealthAlliance-Clinton Hospital Three Pillars: Finance, Quality, and Service Excellence.
- The individual must support the mission, vision, and goals of the Hospital and serve as a role model for the CARES - It Happens Here customer service initiative.
- Demonstrates excellent attendance and actively participates in a variety of meetings and training sessions as required.
- Demonstrates a friendly, responsive, service-minded attitude to all internal and external customers.
- Communicates ideas effectively. Shares information and keeps others properly informed. Gives, and is open to useful feedback.
- Adheres to the Hospital Code of Conduct and Behavior Standards and dress code.
- Complies with established environment of care/safety policies and procedures and all health and safety requirements.
- Maintains, and fosters, an organized, clean, safe work environment.
- Actively contributes to the development and application of process improvements.
- Maintains a collaborative, team relationship with peers and colleagues in order to effectively contribute to the group’s achievement of goals and to help foster a positive work environment.
- Demonstrates respect for the diversity of patient and employee populations. Supports and encourages diverse points of view, work and lifestyles.
- Practices cost containment and fiscal responsibility through the efficient use of supplies, equipment, time, etc.
- Performs a variety of related duties as assigned.
JOB KNOWLEDGE AND SKILLS:
- Ability to establish priorities, meet deadlines and maintain productivity standards in the management of the work assignment.
- Ability to form positive, collaborative relationships with hospital staff, patients, families and post acute providers.
- Ability to problem solve in a proactive, creative manner, using sound judgment based on factual information and clinical knowledge.
- Ability to effectively negotiate with internal and external providers of patient care services.
- Ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirements relative to his/her age-specific needs and to provide the care they need.
- Ability to develop leadership skills and to serve as a role model for clinical staff.
- Ability to work rotating weekends and holidays.
- Strong computer skills including the ability to rapidly learn and use new applications.
- Ability to work independently.
- Ability to read, write and speak clearly in English.
BSN degree preferred or actively working towards BSN. Requisite education for RN is required.
- Minimum of 5 years of broad clinical experience, predominately in medical/surgical nursing. CM, discharge planning and utilization review experience preferred.
An equivalent combination of education and experience which provides proficiency in the areas of responsibility listed above may be substituted for the above education and experience requirements.
LICENSES, CERTIFICATIONS, ETC. :
- Registered Nurse, licensed in Massachusetts.
- Certification in Case Management preferred.