Nurse Case Manager - Case Management 1st Shift

Nurse Case Manager
- Case Management
- Full Time - 1st Shift

#26-751

Stanford, Kentucky, United States

037160 - FLH Case Management

Full Time - 36+ hours per week

JOB SUMMARY

The Nurse Case Manager is responsible for coordinating and facilitating patient care throughout the continuum of care. Working collaboratively with providers, nursing staff, patients, families, payers, and community resources, the Nurse Case Manager promotes safe, efficient, quality, and cost-effective care. Primary responsibilities include care coordination, utilization management, discharge planning, patient advocacy, regulatory compliance, and transition-of-care management. The Nurse Case Manager demonstrates and upholds the Organization's F.I.R.S.T. values of Friendliness, Innovation, Respect, Service, and Trust.

ESSENTIAL FUNCTIONS, DUTIES, AND RESPONSIBILITIES

• Assesses patients for discharge planning, transition-of-care needs, and post-acute service requirements.
• Coordinates care among providers, nursing staff, ancillary departments, patients, families, and external agencies to ensure continuity of care.
• Identifies barriers to care for progression and discharge and implements interventions to facilitate timely resolution.
• Participates in interdisciplinary rounds, patient care conferences, and care planning activities.
• Facilitates evidence-based care delivery and appropriate utilization of healthcare resources to support optimal patient outcomes.

• Performs admission, concurrent, and continued stay reviews using approved medical necessity criteria and payer guidelines.
• Reviews admission status and level-of-care determinations to ensure appropriate patient classification.
• Collaborates with providers and Physician Advisors regarding medical necessity, admission status, documentation requirements, and level-of-care concerns.
• Escalates cases that do not meet established criteria for Physician Advisor review and recommendation.
• Monitors avoidable days, identifies barriers to discharge, and implements strategies to improve patient throughput and optimize length of stay.

• Conducts comprehensive discharge planning assessments in collaboration with the discharge planner and interdisciplinary team.
• Coordinates referrals and arrangements for post-acute services, including but not limited to:
  Home Health Services, Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities (IRF), Long-Term Acute Care Hospitals (LTACH), Durable Medical Equipment (DME), Hospice and Palliative Care Services
• Ensures patients and families are provided freedom of choice regarding post-acute providers in accordance with regulatory requirements.
• Facilitates safe, timely, and effective patient discharges.

• Educates patients and families regarding discharge plans, available resources, insurance benefits, and care transitions.
• Promotes patient participation in care planning and advocates patient preferences while balancing clinical and payer requirements.
• Provides education regarding community resources and post-discharge support services.

• Ensures compliance with CMS Conditions of Participation, Medicare regulations, Medicaid requirements, and payer guidelines.
• Delivers and documents required patient notices, including but not limited to:
• Maintains accurate, timely, and complete documentation within the electronic medical record.
• Participates in audits, surveys, and compliance reviews as assigned.

• Communicates effectively and professionally with patients, families, providers, payers, and…