Case Manager

Job Profile Summary

This role focuses on providing professional and nonprofessional nursing care services in accordance with physician orders. In addition, this role focuses on performing the following Clinical Nurse duties:
Assesses, plans, implements, and evaluates the care needs of a designated group of patients or provides nursing care and identified clinical support tasks within the scope of practice for achievement of the patient's plan of care as directed. Provides professional nursing care to patients. Requires a nursing license. A professional individual contributor role that may direct the work of other lower level professionals or manage processes and programs.

The majority of time is spent overseeing the design, implementation or delivery of processes, programs and policies using specialized knowledge and skills typically acquired through advanced education. A senior level role that requires advanced knowledge of job area typically obtained through advanced education and work experience. Typically responsible for: managing projects/processes, working independently with limited supervision, coaching and reviewing the work of lower level professionals, resolving difficult and sometimes complex problems.

This position is responsible and accountable for the management of care for an assigned patient population by unit, across the continuum of care. The Case Manager works to achieve daily clinical, quality and cost outcomes by providing well-coordinated experiences for patients/families through the synchronization of care activities of multiple disciplines and negotiating with third party payors. This is accomplished by negotiating, procuring and coordinating services and resources needed by patient/family;

ensuring and facilitating the achievement of quality and clinical customer service; cost and clinical outcomes; intervening at key points for individual patients; addressing and resolving patterns or issues that have a negative quality-cost impact; and creating opportunities and systems to enhance outcomes.

• Associate's Degree in Nursing.
• Basic Life Support (BLS) Certification.
• Registered Nurse (RN) License.
• Three (3) years of Case Management experience.
• Certifications (i.e. ACLS, PALS) relevant to the department and type of care being provided may be required.

• Bachelor's Degree in Nursing.

• Complete assessments on all new admissions to determine the need for all appropriate Case Management services.
• Conduct daily multidisciplinary rounds on assigned units, review patient's plan of care and coordinate including:
  Assessment of patient/family needs;
  Completion and report of diagnostic tools in a timely manner;
  Completion of treatment appropriate for the acute episode of illness;
  Modification of plan to meet continuing care needs of the patient; and monitoring ongoing process of gathering adequate information from all relevant sources to insure operation of plan.
• Discuss estimated length of stay, treatment and discharge plan with the attending physician and healthcare team by establishing strong, collaborative relationships with physicians and team members and discussing the appropriateness of resource utilization, consults and treatment plan.
• Ensure that the interdisciplinary care plan and discharge plan are consistent with the patient's clinical course, covered services and continuing care needs.
• Identify patients and families with complex psychosocial, financial and legal discharge planning needs and refer them to social work.
• Incorporate knowledge of clinical expertise, quality initiatives, insurance and finance into decision-making and problem solving of individual patient cases and across case type during care management activities.
• Foster and maintain a positive working relationship with referral agencies and liaisons to enhance patient flow.
• Collect and report on quality projects, e.g. CHF;
  Re-admissions within 30 days;
  Delay Day Variances;
  Risk management; and Quality improvement.
• Document patient/family progress toward discharge and all critical events and information associated with the hospital stay in Soft Med.
• Support the EMR and all computer programs, including Soft Med and Soarian.
• Using Interqual criteria, review appropriateness of admission, the need for continued stay and information needed for discharge.
• Respond to third party payor requests for concurrent clinical information in a timely manner.
• Ensure that documentation in the medical record supports the admission and continued stay, in order to reduce denial rate.
• Document care management activities in the initial assessment and as the patient progresses toward discharge and at discharge.
• Interact with Admitting, Financial Counselors, Insurance Case Managers, Finance and Screeners as appropriate.
• Maintain clinical competency and current knowledge of regulatory and payor requirements to perform job responsibilities.
• Work with documentation specialist…