Registered Nurse Case Manager (RN) - Case Management

Job Summary

The RN Case Manager is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care, and appropriate utilization of resources, balanced with patient resources and right to self-determination. The individual has overall responsibility for ensuring that care is provided at the appropriate level based on medical necessity and to assess the patient for transition needs to promote timely throughput, safe discharge, and prevent avoidable readmissions.

This position integrates national standards for case management scope of services including utilization management, transition management, care coordination, compliance with state and federal regulations, TJC accreditation standards, and Tenet policy. Education is provided to physicians, patients, families, and caregivers.

• Accurate medical necessity screening and submission for Physician Advisor review.
• Care coordination.
• Transition planning assessment and reassessment.
• Implementation or oversight of transition plans.
• Lead and facilitate multidisciplinary patient care conferences.
• Manage concurrent disputes.
• Appropriate referrals to other departments.
• Identify and refer complex patients to Social Work Services.
• Communicate patient care plan to patients and families.
• Collaborate with physicians, office staff and ancillary departments.
• Lead and facilitate Complex Case Review.
• Assure patient education is completed to support post‑acute needs.
• Timely complete and concise documentation in Case Management system.
• Maintain accurate patient demographic and insurance information.
• Identify and document potentially avoidable days.
• Identify and report over and under‑utilization.
• Perform other duties as assigned.

Balance clinical and financial requirements and resources in advocating for patient needs with judicious resource management. Ensure the patient is in the appropriate status and level of care based on medical necessity and submit cases for secondary physician review. Promote prudent utilization of all resources by evaluating available resources and balancing cost and quality to assure optimal clinical and financial outcomes.

Identify and document avoidable days, prevent denials and disputes, and coordinate clinical care, comparing to evidence‑based practice, internal and external requirements.

Complete comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan. Integrate key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan. Identify patients at risk for readmission and apply appropriate interventions, including risk assessment and referral to Social Work services or Complex Case Review. Follow up to ensure the transition plan is completed timely and accurately.

Screen patients for factors that may affect the progression of care and intervene as needed to promote timely and appropriate throughput. Conduct assessments and stratify patients at risk for readmission or in need of case management services. Ensure the plan of care is clinically appropriate, consistent with patient choice and available resources. Ensure consults, testing and procedures are sequenced to support the patient’s clinical needs with timely and efficient care delivery.

Ensure and provide education to patients, physicians and the healthcare team regarding appropriate level of care, safe and timely patient transition, and resources and benefits available to the patient.

Ensure compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services. Adhere to department structure, staffing, policies and procedures to comply with CMS Conditions of Participation and Tenet policies.

• Graduate from an accredited school of nursing. Bachelor’s degree in nursing or other health‑related field, or equivalent combination of education and/or related experience.
• Two years of acute hospital patient care experience. Acute hospital…