CASE MANAGER

Job Summary

The hospital case manager coordinates patient care, ensuring a smooth transition through the hospital stay and beyond. They assess patient needs, develop care plans, and facilitate communication between patients, families, and the healthcare team. Case managers also play a key role in discharge planning and utilization review, helping patients access appropriate resources and services.

• The case manager plans, coordinates, develops, evaluates, and monitors the care of assigned group of patients to achieve quality cost-effective patient outcomes.
• Completes & documents in the EMR a discharge assessment on all assigned patients, including meeting with all new admissions to assess and discuss a proposed discharge plan and following the progress of the discharge plan until discharged.
• Attends daily care management team meetings on the assigned unit.
• Works collaboratively with interdisciplinary teams to identify services required to meet patient and family needs throughout the continuum of care, ensuring appropriate resources are implemented in a timely manner.
• Identifies and arranges appropriate post‑discharge services such as Home Health Care (HHC), Hospice, Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Long Term Acute Care Hospital (LTACH), Durable Medical Equipment (DME), or returns back to nursing home.
• Communicates in a timely manner with the appropriate payer to initiate authorization for identified post‑hospital services.
• Demonstrates knowledge and skills to appropriately communicate and interact with patients, families, and visitors while being sensitive to cultural and religious beliefs.
• Collaborates with physicians, physician’s office staff, and registration staff to obtain necessary information to support medical necessity and the medical review policies, validating the appropriateness of admission, services, and continued stay; issues letters of non‑coverage as indicated.
• Collaborates with registration staff regarding physician orders for correct patient status assignment (Inpatient or Observation).
• Issues Medicare hospital notices as indicated.
• Collaborates with physician advisors and attending physicians for questioned admissions to ensure guidelines are followed for issued notices or an appeal of discharge.
• For patients at risk for readmission, identifies and addresses the cause(s) of readmission to avoid further readmission when applicable.
• In the Utilization Management (UM) role, performs admission reviews to ensure patients meet identified clinical criteria and are assigned the correct admission status (Inpatient or Observation); the UM nurse continues to monitor this throughout the hospital stay.
• Performs timely level‑of‑care reviews on assigned patients, provides clinical updates to third‑party payers, and obtains authorization as indicated.
• Consistently follows up and updates authorization/certification information on an ongoing basis.
• Records, reports, and documents denials and appeals for the assigned group of patients; follows up with physician advisor, denial coordinator or other designated staff.
• Functions as the central liaison between Medicare QIO, review agencies, Business Services, Patient Financial Services, and other healthcare professionals affected by concurrent review, DRG assignment, the certification process, and discharge planning.
• Is involved in utilization review activities as defined by the utilization management process; participates in various committees/task forces as needed.
• Assists team leader with training new staff or other tasks as needed; assembles, analyzes, monitors, and tracks data for reporting as designated by the Director.

• Responds positively to change and can handle multiple tasks.
• Accomplishes work in ways that maximize productivity.
• Manages daily workload efficiently.
• Builds respectful relationships with internal and external customers.
• Adheres to regulatory guidelines.
• Advocates for and represents case management initiatives positively when working with others.
• Learns and follows various regulatory guidelines.
• Demonstrates patient safety and infection control practices.
• Follows…