Case Mgr, RN- Case Management

Job Description

Serves as liaison between the patient and facility/physician. Ensures a continuum of quality patient care throughout hospitalization and oversees provisions for patient's discharge. Assesses, plans, oversees and evaluates the appropriateness of care throughout admission and hospitalization of the patient.

• Facilitates patient management throughout hospitalization.
  • Participates in patient management rounds and patient centered meetings.
  • Identifies potential delays and resolves issues with appropriate departments.
  • Identifies appropriate utilization of Social Work Services and makes referrals when appropriate.
  • Confers with physician regarding referrals for Physical Therapy, nutrition, speech and swallow.
• Serves as an in‑patient liaison – planning, assessing, implementing and evaluating patient in collaboration with the health care team.
  • Serves as a resource to the health care team regarding quality, utilization of clinical resources, payer, and reimbursement issues.
  • Works with on‑site screeners in transitioning patients to appropriate post discharge settings.
  • Collaborates with payers, providing all necessary clinical documentation for the maximization of benefits.
  • Serves as a liaison to patient, family, admitting, primary care physician, health care team, and hospital departments.
  • Collaborates with and provides feedback to the primary care physician and multidisciplinary team regarding patient’s status with regard to length of stay, utilization of resources and discharge status.
• Provides support to the in‑patient health care team as well as to patient and family regarding all aspects of admission, hospitalization and discharge plan.
  • Involves patient and/or family in discussion and planning for anticipated need for care following discharge.
  • Ensures patient and/or family are given information regarding their choices regarding transferring the patient to another level of care according to regulatory standards.
• Conducts chart review for appropriateness of admission and continued length of stay.
• Contacts and interacts with third party payers to obtain approval of hospital days, pre‑certification and post‑discharge eligibility in relation to clinical course.
• Ensures compliance with current state, federal, and third party payer regulations.
• Identifies patients for Alternate Level Care (ALC) care list and notifies appropriate health team members.
• Communicates with insurance companies and physicians regarding utilization issues.
• Utilizes important message from Medicare (IMM) when appropriate.
• Ensures managed care reviews are up to date and accurately reflect patient’s clinical progress and acute needs.
• Participates in the quality management of patient care outcomes.
  • Submits data to management regarding case management and/or quality initiatives.
  • Participates in data collection regarding patient’s length of stay, utilization of clinical resources, IPRO citations including appropriate recommendations and re‑admission within 30 days.
• Initiates appropriate discharge planning as supported by initial assessment at time of admission.
  • Reviews patient’s chart.
  • Assess each patient physically, psychosocially and financially.
  • Assess patient’s support system to facilitate appropriate discharge to community.
  • Substantiates, with the physician, the need for home care services.
  • Coordinates procurement of any supplies, equipment or home lab work needed by patient to evaluate discharge.
  • Arranges for post‑hospital transportation when indicated.
  • Interacts and coordinates with community agencies, families, vendors, facilities and institutions to facilitate patient discharge.
• Documents the case management process in the medical record.
  • Completes and documents a psychosocial assessment on the patient.
  • Documents ongoing processes of patient’s hospitalization.
  • Documents finalized discharge plan and disposition.
  • Completes applicable areas of the Patient Discharge Instruction Sheet and the Patient Transfer Sheet.
  • Ensures Patient Review Instrument (PRI) is completed and reflects clinical profile of the patient.
  • Ensures case management sheet is current and accurate.
• Performs related duties, as required.

* ADA Essential Functions