Case Manager RN

Case Manager RN

Are you looking to make a difference by improving the health of our patients? Here you will find an innovative culture that is patient-focused and dedicated to making a difference. We are committed to helping the population we serve, and our communities, achieve optimum health and enjoy the best quality of life possible.

The Case Manager RN supports the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates and coordinates utilization management, care facilitation, and discharge planning functions. The Case Manager is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources.

Specific functions within this role include:

• Facilitation of precertification and or payor authorization processes
• Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement
• Application of process improvement methodologies in evaluating outcomes of care
• Support and coaching of clinical documentation efforts
• Coordinating communication with physicians

Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the patient served.

• Coordinates/facilitates patient care progression throughout the continuum.
• Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management.
• Addresses/resolves system problems impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge.
• Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge
• Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Collaborates with physician and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis:
• Completion and reporting diagnostic testing
• Completion of treatment plan and discharge plan
• Modification of plan of care, as necessary, to meet the ongoing needs of the patient
• Communication to third party payors and other relevant information to the care team
• Assignment of appropriate levels of care
• Completion of all required documentation in Milliman and EPIC
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in appropriate setting.
• Completes utilization management and quality screening for assigned patients.
• Applies Milliman Criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Department standards.
• Identifies at-risk population using approved screening tool and follows established reporting procedure
• Monitors LOS and ancillary resources on an ongoing basis. Takes action to achieve continuous improvement in both areas.
• Refers cases and issues to Case Review, Utilization Committee, Medical Director, and Director of Quality in compliance with department procedure and follows up as indicated.
• Communicates with Finance Department on issues of insurance, denials, authorizations and self-pay issues as needed
• Interfaces with IPRO and other review agencies regarding denials, retrospective reviews.
• Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Manages all aspects of discharge planning for assigned patients.
• Meets directly with patient/families to assess needs and develop an individualized continuing care plan in collaboration with physician.
• Collaborates/communicates with Multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, and teaching and ongoing evaluation.
• Ensures/maintains plan consensus from patient/family, physician and payor.
• Refers appropriate cases for social work intervention based on department criteria.
• Collaborates/communicates with external case managers, admissions personnel.
• Initiates and facilitates referrals for home health care, durable medical equipment and supplies.
• Maintains a current knowledge of resources available within the community and maintains a supply of resource materials to be distributed to patients when needed.
• Documents relevant discharge planning information in the…