RN Care Manager - Phoebe Sumter Hospice

Overview

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. 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, 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 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)

• Perform utilization review and discharge/transition planning functions and activities per assigned caseload or unit.
• Apply knowledge of regulations and payer requirements to maintain full compliance, assure patient rights and avert payer denials or patient liability.
• Notify the Physician Adviser designee, or Chief Utilization Officer, as needed regarding physician issues, patient care issues or quality issues.
• Perform prospective or concurrent review of patient medical records; apply clinical criteria for admission and continued stay based on severity of illness and intensity of service needs; may perform retrospective review as required.
• Educate physicians, nurses and other hospital personnel regarding CM processes, and payer or regulatory agency policies and regulations.
• Ensure an appropriate plan‑of‑care has been established, including an appropriate discharge plan; intervene and facilitate as needed.
• Provide patient/family specific education regarding discharge services, options, and providers of care or services.
• Discuss payer authorizations or actions needed by patient/family to secure financial obligations for transition planning needs.
• Assess clinical evaluations and documentation related to assigned patients' medical diagnosis and clinical treatment plan; consider impact of plan along with emotional, cultural and psychosocial factors.
• Identify patient and family needs related to medical diagnosis, treatment plan, care options and financial resources for discharge planning.
• Identify risk factors and make timely referrals to appropriate disciplines, agencies, or community resources.
• Identify actual or potential delays in care, intervene with physicians, nursing and other health system departments to promote timeliness of care and service and prevent delays.
• Perform care management assessment for patient appropriate level of care and treatment setting.
• Formulate an individualized patient plan and coordinate with Social Worker to determine priorities for timely planning and safe transition.
• Facilitate coordination of care among caregivers, and across acute and post‑acute care settings.
• Engage patient/family or significant other in planning and decisions as legally appropriate.
• Perform systematic assessment and periodic…