Registered Nurse - Case Management

The Case Manager has a day-to-day responsibility for assessing the medical necessity of patient admissions, and continued stays,based on the clinical documentation in the Electronic Health Record (EHR) in accordance with Milliman Care Guidelines (MCG).The Case Manager assists in coordination of care among multidisciplinary team members such as Medical Attending's, Residents,Interns, Specialists, Social Workers, Nursing, Dietary, Finance, and Clerical staff.

Case managers identify triggers to re-admissions and needed community/social/financial support to maintain appropriate and safe discharges related to ongoing medical management of patient care needs.

The goals of the Case Management services are to identify Physician and staff documentation opportunities to support Quality andPay for Performance indicators and execute prudent and sequential care by bringing about awareness to all treatment team members on length of stay reduction, and advocacy for compliance to plan of care.

Case Managers are expected to have strong clinical backgrounds, and advocate for safe, timely adherence to executing the patient plan of care. Job training is available in addition to meeting the core qualifications for this position.

• Performs face-to-face visits with patients that need assessment of physical, mental, and emotional barriers that prohibit self-care, prompt medical management assistance in the community, and initiation of referrals to social work by using nursing clinical judgment
• An interdisciplinary care team member responsible for daily EHR review of patient’s medical necessity (severity of illness andintensity of service); either in bedside rounds, or Interdisciplinary team rounds
• Collaborate with social workers on identification on any social determinants of health domains, that could impede patients’health outcomes
• Functions as a liaison between Physicians and Physician Advisors
• Demonstrates the ability to correlate medical necessity (severity of illness and intensity of service) in achieving financial and
• quality care outcomes
• Monitors the electronic health records (EHR) daily or as needed, for assigned patients, and complete clinical documentation pertaining to hospitalization for submission to insurance companies (Initial, Concurrent or Retroactive)
• Reviews all HMO admissions for medical necessity and submit to HMO
• Reviews admissions for medical necessity (severity of illness and intensity of service) within forty-eight hours of admission
• Knowledge of Milliman Care Guidelines
• Knowledge of CMS guidelines for post-acute placements
• Communicate with Attending Physicians on admission guidelines
• Provide real time interventions to prevent delays and ensure compliance and revenue integrity with health care regulations
• Informs treatment team members of recommended EHR documentation needed based on Milliman Care Guidelines for approval of admission, transfer, length of stay, and safe discharge planning
• Identifies tests, procedures, and interventions early to advance the plan of care.
• Assess, and collaborate with the health care team the need for Alternate Level of Care designation. Document in EMR when
• patient is placed on ALC
• Assess current support and adherence to medical care in the community, with the evaluation of effectiveness towards health promotion
• Collaborate with treatment team members to create a care plan to reduce re-admission rates by identifying barriers to care
• and resolutions to those barriers
• Responsible for completion of home IV infusion and related home care referral to IV infusion companies and follow up with patient/family
• Responsible for completing wound vac and related home care referral for patients discharged home with wound vac.
• Makes appropriate referral to financial…