Case Management, Utilization Review, and Swing Bed Coordinator

The Case Manager / Utilization Review / Swing Bed Coordinator (CM) will facilitate the interdisciplinary plan of care with a focus on evaluating the appropriateness of clinical care, medical necessity, admission status, level of care, and resource management. The CM will coordinate activities that promote quality outcomes and patient throughput while supporting a balance of optimal care and appropriate resource utilization.

The CM will identify potential barriers to patient throughput and quality outcomes and will facilitate appropriate discharge plans. The population served includes all observation, inpatient, and swing bed patients that present to Calhoun Liberty Hospital for medical treatment. This position operates within the confines of the hospital building and general office environment.

As the only Registered Nurse in the Case Management Department, the colleague will be responsible for directing, designing, managing, monitoring, and evaluating all operational functions and activities of case management / discharge planning and utilization review which includes developing policies consistent with CLH regulations. Working with the Chief Nursing Officer, providers, and members of related department, the CM will aim to improve the Swing Bed program within the hospital by providing patient support through placement screening, admission and discharge assistance, providing educational resources to patients and their families, and developing policies consistent with CLH regulations to support the Swing Bed program.

• Actively seeks ways to control cost without compromising patient safety, quality of care, or the services delivered
• Follows established guidelines for reporting a significant medical error or unanticipated outcome in the patient’s care which results in patient harm
• Attends inservice presentations and completes all mandatory education requirements
• Uses Performance Improvement Plans to improve patient safety
• Regular, punctual, and dependable attendance
• Will work directly with the Director of Patient Care Services and Chief Nursing Officer to assist with data collection for submission to the Utilization Review Committee and Medical Staff /Peer Review
• Other duties as assigned

• Performs daily (MF) medical necessity reviews utilizing approved criteria
• Collaborates with the registration/business department to ensure payer notifications/authorization requests have been made
• Escalates cases to the Chief of Staff when criteria for admission are not met
• Documents variances in the EMR
• Communicates with the Interdisciplinary Team (IDT)
• Coordinates and facilitates the appropriate care with the Patient, Physician, and IDT
• Performs continued stay reviews and communicates information to third party payers
• Refers cases (including those with excessive lengths of stay) as needed to Chief of Staff
• Other duties as assigned

• Performs a comprehensive initial and ongoing assessment of psychosocial, medical, and discharge needs of assigned patients; plan is documented in the medical record and communicated to the IDT during team meetings; assesses appropriateness of treatment
• Ensures the appropriateness and timeliness of clinical interventions for targeted patient population
• Assesses the patient’s goals and care plan with the IDT along with nursing staff; ensures it is updated and communicated to the patient and family
• Coordinates the timely and safe transition to the next level of care when appropriate
• Acts as a liaison through effective and professional communication between the physicians, patients / families, hospital staff, and outside agencies
• Makes appropriate referrals to third party payer’s disease and case management programs for reoccurring patients and patients with chronic disease status
• Facilitates patient throughout stay with an ongoing focus on quality and efficiency
• Assesses patient’s post discharge needs and facilitates the provision of services necessary to meet their complaint
• Other duties as assigned

• Works with the Director of Patient Care Services, providers, and team members to effectively improve the…