RN Case Manager - Acute Rehab

Overview

To provide a comprehensive approach to case management inclusive of all aspects of the patient’s stay including, but not limited to the following key functions: discharge planning and execution of the discharge plan; ensuring proper utilization management requirements of payers are met; identification and capture of key clinical conditions by physician documentation; and institution of actions to support quality and safety initiatives.

Certifications:

Licensed Registered Professional Nurse (RN) – Illinois Department of Financial and Professional Regulation (IDFPR);
Certified Case Manager within 2 years – Commission for Case Manager Certification (CCMC).

Education:

College Diploma:
Nursing.

Work Experience:

Acute care.

Performs intensity of service/severity of illness/disease specific reviews throughout patient stay.

• Applies and documents medical necessity reviews on admission and continued stay
• Notifies appropriate parties (physicians, nursing staff, patient, families, and other members of the care team as appropriate) when patients not meeting criteria and initiates measures to mitigate risk (discharge or better documentation to support clinical situation)
• Demonstrates accurate documentation of medical necessity reviews
• Achieves a 90% inter-rater reliability score related to random audits regarding the use of guidelines and accurate documentation of clinical picture
• Assists in denial management mitigation by using Medical Director/E H R
• Uses GMLOS to help manage length of stay as well as other criteria to move patient efficiently through continuum of care
• Demonstrates ongoing assessment for next level of care and actions to move patient to appropriate level (LTAC, Long term care, Hospice, Home Care etc.)
• Communicates with insurance companies to ensure accurate documentation for reimbursement.
• Coordinates and submits pertinent documentation to meet medical necessity during patients’ stay.
• Collaborates and conducts a comprehensive care plan meeting with patients, family, and interdisciplinary team (IDT) to ensure all discharge needs are met.
• Develops individualized discharge care plans in EMR.
• Maintains current with changes to Patient Driven Payment Model (PDPM) for maximum reimbursement.
• Consistent communication with Managed Care companies regarding continued stay, covered days and any discrepancies.
• Notifies appropriate staff of any discrepancies with documentation requirements.
• Incorporates input from patient and family to ensure an individualized plan of care is in place to best fit the patient’s needs while on TCC and upon discharge.

Performs and executes discharge planning within the first 24 hours of patient stay.

• Performs accurate and timely screening of patients for discharge needs
• Develops sound and reliable discharge plans incorporating risk for readmission assessment in discharge needs and support structure
• Includes all stakeholders in the discharge plan to ensure plan is sound and fully communicated
• Ensures assessments and plans documented in EMR and other required documents
• Participates in multidisciplinary rounding process as requested
• Works collaboratively with all caregivers in the continuum of care to ensure sound and timely discharge plan
• Manages LOS and resource utilization
• Demonstrates strong understanding and mastery of community resources
• Possesses strong discharge planning assessment skills
• Communicates well and frequent with patients and families
• Performs readmission screens and takes action to mitigate readmission risk (use of post discharge resources, medication planning, etc.)
• Ensures referrals to other needed disciplines as deemed by assessments (physical therapy, dietary) are made timely early in stay
• Works collaboratively with nursing and other members of the care team, to ensure issues that Case Management identifies, are included in the plan of care
• Organizes and leads multidisciplinary care conferences as necessary to facilitate plan of care progression.
• Adheres to CMS COP:
  Discharge Planning

Assist in facilitation of organizational and unit based quality initiatives and documentation in EMR.

• Incorporates key quality assessment points with daily rounding on…