Registered Nurse; 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 the patients resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care 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, and education.

• Accurate medical necessity screening and submission for Physician Advisor review.
• Care coordination.
• Transition planning assessment and reassessment.
• Implementation or oversight of the transition plan.
• Leading and facilitating multidisciplinary patient care conferences.
• Managing concurrent disputes.
• Making appropriate referrals to other departments.
• Identifying and referring complex patients to Social Work Services.
• Communicating with patients and families about the plan of care.
• Collaborating with physicians, office staff and ancillary departments.
• Leading and facilitating Complex Case Review.
• Assuring patient education is completed to support post‑acute needs.
• Timely completion and concise documentation in the Case Management system.
• Maintenance of accurate patient demographic and insurance information.
• Identification and documentation of potentially avoidable days.
• Identification and reporting of over and under utilization.
• Other duties as assigned.
• Balancing clinical and financial requirements to advocate for patient needs and judicious resource management.
• Submitting cases for Secondary Physician review per Tenet policy.
• Ensuring timely communication of clinical data to payers to support admission, level of care, length of stay, and authorization for post‑acute services.
• Advocating for the patient and hospital with payers to secure appropriate payment.
• Promoting prudent utilization of all resources by evaluating available resources and balancing cost and quality.
• Identifying and documenting avoidable days for opportunities for improvement.
• Preventing denials and disputes by communicating with payers and documenting relevant information.
• Coordinating clinical care compared to evidence‑based practice, internal and external requirements.
• Completing comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan.
• Integrating patient assessment, choice and available resources to develop and implement a successful transition plan.
• Identifying patients at risk for readmission and applying appropriate intervention including risk assessment and referral to Social Work services or Complex Case Review.
• Delegating implementation of the transition plan to LVN/LPN or Assistant staff when appropriate.
• Following up to ensure transition plan is completed timely and accurately.
• Ensuring all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post‑acute providers.
• Providing information to patients to make informed choices regarding community services per Tenet policy.
• Completing Final Discharge Disposition Form Assessment for Medicare patients per Tenet policy.
• Identifying and reporting variances in the appropriateness of medical care provided and over/under utilization compared to evidence‑based practice and external requirements.
• Ensuring patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care.
• Eff…