SAH RN Case Manager

SUMMARY

Promotes the development of high quality patient care in the most effective setting, balancing patient/hospital advocacy. Knowledgeable of third party payor issues. Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done.

The core Success Factors include:

• Instill Trust and Value Differences
• Patient and Community Focus and Collaborate

• Coordinates patient care across the continuum of care
• As needed, strives to maximize and mobilize all internal and external resources that facilitate the case management process for all assigned cases
• Documentation always reflects patient plan of past hospital care and, if applicable, interdisciplinary coordination
• As needed, provides a nursing assessment within 24-48 hours of patient admission for clinically oriented services focused on mobilizing primary care physician, hospital systems, patient/family and community resources directed towards facilitating a clinically safe and timely discharge
• Identifies problems and gaps in patient care when covering for unit case manager
• Suggested interventions, expedited interdisciplinary referrals and ensured diagnostic testing is completed and reported within appropriate timeframe
• Actively participates in patient care conferences as scheduled on nursing units when covering for the unit case manager
• Works collaboratively with medical staff, nursing and other therapeutic disciplines in developing and implementing a patient plan of care while covering for case manager
• Follows plan of care initiated by unit case manager
• Initiates initial plan of care for new patients assigned
• Clinically documents patient plan of care, progress, goals, and interventions according to Case Management Department, Federal, and State guidelines
• Maintains a professional working relationship with Managed Care Organization telephonic and on site reviewers and external reviewing agencies in monitoring course of hospitalization and need for post hospital services according to third party payor guidelines
• Returns all calls from managed care organizations occurring on day covering the case
• Community health care agencies and third party payor utilization review agencies are provided with patient care information through allscripts that is concise, accurate and communicated in a timely manner
• All reviews assigned to per diem case manager sent when completed unless review referred for second level review
• Monitors utilization of resources
• Exercises professional authority intervening when necessary with physicians /therapeutic disciplines to remove barriers that impact length of stay
• Communicates via allscripts to unit case manager any issues identified while covering unit
• Always demonstrates awareness of over or under utilization of resources and responds accordingly
• Appropriately monitors utilization of resources for caseload assigned
• Demonstrates understanding and has accurately applied severity of illness intensity of service criteria according to third party payor guidelines, appropriately identifying levels of care for all assigned cases
• Maintains ongoing dialogue with medical staff, nursing and other involved therapeutic disciplines relative to utilization and length of stay issues and communicates via Allscripts to unit case manager
• Demonstrates initiative in exploring strategies to reduce length of stay and resource consumption within complex case managed patient populations
• Effectively identifies patients for complex management versus those patients with less significant needs care
• Communicates with other members of healthcare team regarding patients’ needs, plan and response to
• As needed, offers assistance/solutions to physicians in resolving external third party payor issues
• Negotiates, procures, and coordinates service and resource
• Based on third party payor criteria, always works with patients/families/physicians to effect a positive length of stay outcome
• Always demonstrates critical thinking and sound clinical judgment in matters of patient advocacy versus conflict with the third party payor requirements
• Establishes patient/family contact within the timeline required by department policy and explains case management role
• Identifies with patient/family expected length of stay and planned outcomes throughout the episode of acute hospitalizations
• Demonstrates a working knowledge of the resources available in the community for patients/families
• Ensures through coordination and collaboration with primary care physician and nursing that appropriate hospital services maximizing patient independence is initiated
• Expeditiously and appropriately identifies and refers those patients in need of short term skilled/long term chronic care
• Manages…