RN Care Manager - Phoebe Sumter Hospice

Job Summary

The Nurse Case Manager (CM) is responsible for care coordination of patients along their continuum from point of entry through discharge. The CM will address issues related to appropriate and timely admission, discharge, and care for patients receiving inpatient and observation care and services at PPHS facilities. The Care Manager performs first level clinical reviews according to hospital approved clinical criteria and in accordance with the Care Management Program's Utilization Plan and payer specific requirements.

He/she will address utilization of resources for efficient and effective care delivery at the appropriate level of care. The Care Manager collaborates with social work, physicians, nurses and multidisciplinary team, lending professional care management expertise to ensure quality, timely and cost effective case management for an identified patient population and addresses issues or patterns in patient readmission. In this role the Care Manager is accountable for facilitating clinical patient progression through a defined plan of care to achieve optimal outcomes.

Under the direction of the Care Management Team Lead and the Director of Care Management, and through coordination with nursing, social work, physicians and other members of the interdisciplinary team, the Care Manager develops, facilitates and implements appropriate case management and discharge plans.

• Associate's Degree in Nursing from a state accredited school (Required)
• Bachelor's Degree in Nursing from a state accredited School of Professional Nursing (Preferred)
• 3 or more years of recent acute care experience with relevant clinical experience in the assigned area (Required)
• 1 or more years of Case Management or Utilization Review experience in a hospital or related setting (Preferred)
• Registered Nurse (RN) with current Georgia license (Required)
• Certified Case Manager (CCM) (Preferred)

JOB KNOWLEDGE - CARE MANAGER
Understands and fulfills job responsibilities and expectations and applies knowledge and skills to function proficiently in CM role.
Serves as Patient Advocate in support of Hospital mission and goals.
Maintains knowledge of current federal, state and accreditation requirements applicable to utilization review and discharge planning; demonstrates skill in the application of this knowledge.
Possesses current and comprehensive skill and knowledge to perform all parts of the job effectively and efficiently.
Exhibits ability to learn and apply new skills, professional knowledge and expertise.
Requires minimal day-to-day direction to perform responsibilities.
Acts as resource in area of specialty and is able to share best practices and answer questions as needed.
UTILIZATION MANAGEMENT AND DISCHARGE PLANNING
Performs utilization review and discharge/transition planning functions and activities per assigned caseload or unit.
Applies knowledge of regulations and payer requirements to maintain full compliance, assure patient rights and avert payer denials or patient liability.
Notifies the Physician Adviser designee, or Chief Utilization Officer, as needed regarding physician issues, patient care issues or quality issues. Seeks guidance and intervention as necessary; discusses or escalates cases to Team Lead or Director CM for guidance or administrative support.
Performs prospective or concurrent review of patient medical records; applies established clinical criteria for admission and continued stay based on severity of illness and intensity of service needs; may perform retrospective review of same as required.
Educates physicians, nurses and other hospital personnel regarding CM processes, and payer or regulatory agency policies and regulations.
Ensures that an appropriate plan-of-care has been established, including an appropriate discharge plan. Intervenes and facilitates as needed. Serves as a resource to nursing staff and social workers in complex patient discharge issues.
Provides patient/family specific education regarding discharge services, options, and providers of care or services.
Discusses payer authorizations or actions needed by patient/family to secure financial obligations for transition planning needs.
Assesses clinical evaluations and documentation related to assigned patients' medical diagnosis and clinical treatment plan; considers impact of plan along with emotional, cultural and psychosocial factors.
Identifies patient and family needs related to medical diagnosis, treatment plan, care options and financial resources for discharge planning. Identifies risk factors and makes timely referrals to appropriate disciplines, agencies, or community resources.
Identifies actual or potential delays in care, particularly those which may result in issues with quality of care, lack of medical necessity or payment/authorization denial. Intervenes with physicians, nursing and other health system departments to promote timeliness of care and service and to prevent delays in care.
ASSESSMENT,…