Registered Nurse,Care Manager Job Warwick area,Rhode Island USA,Nursing

Job Summary

The RN Care Manager (RN CM) performs utilization management, case management and discharge planning activities for acute care, and/or extended care patients including ambulatory and emergency department patients. The RN Care Manager works with the patient health care teams to assess patients transition/discharge planning needs, actively prevent unnecessary admissions/readmissions, and facilitate timely transitions/discharges.

Duties & Responsibilities

Per the hospital Utilization Management Plan, the RN CM performs utilization and resource management by assessing and reassessing the patients’ medical necessity to ensure accurate status (i.e. inpatient, observation, or ambulatory care) and documents the timely, appropriate use of evidence-based criteria, e.g. Inter Qual.

Responds to all insurer requests for information and collaborates with onsite review nurses e.g. regarding insurance authorization. Conducts medical record review for level of care (LOC)/disposition planning. Reassesses LOC timely to ensure appropriateness. Discusses LOC and medical necessity with attending physician daily.

Communicates to patient and/or patient’s families, e.g. medical necessity, goal length of stay, projected discharge date. Identifies, actively intervenes escalation of system delays for secondary review, and provider-related delays for secondary medical review (i.e. physician advisor, or Chief Medical Officer) and tracks delays e.g. potential or actual avoidable days. Proactively identifies patients readiness to transition and intervenes timely, e.g. downgrade, or discharge to a post-acute care.

Screen surgical procedures for medical necessity, e.g. SIMS plus.

Demonstrates compliance with all Federal and State regulations as it pertains to LOC assignment and medical necessity, e.g. Two-Midnight Rule and certification.

Proactively manages denials and third party payer reimbursement from preadmission through post-discharge in collaboration with the Patient Financial Services Department (PFS). May execute/delegate patient notices, e.g. HINN, Condition Code 44, Important Message from Medicare, Detailed Notice of Discharge, patient liability, etc. Acts as a resource to PFS, e.g. uninsured patients accessing Health Care insurance. Conducts real time follow-up on concurrent payer denials, e.g. facilitates peer to peer discussions, and completes Medicare short stay reviews and collaborates with appeals representatives.

Performs timely patient and family assessments to predict the patient’s risk of readmissions, discharge planning needs and family/significant other health literacy, e.g. in the Emergency Department, within 24 hours of a direct admission, or pre-admission when planned, elective surgery. Fosters patient flow and throughput by coordinating patients’ transition through the hospital via strategic activities to manage length of stay, cost of care and optimize each hospital day.

With the patient care team, assesses patients teaching needs for a safe care transition to the next care setting. Completes interventions prior to e.g. emergency department and during hospitalization, coordinates the patient’s overall discharge/transition plan with the patient health care team. Proactively initiates patient referrals, e.g. social services.

Facilitates and participates in daily collaborative care rounds, and assures all members of the team know patients goal length of stay (GLOS), projected discharge date, plan for disposition and risk for readmission.

Coordinates key interventions among members of the interdisciplinary care team, ensuring patient care is provided in a timely manner. Participates in the hospital based patient flow efforts/teams.

Develops and documents specific treatment plan, documents and discusses with the patient care team and assures patient’s understanding of his or her role with managing disease process. Identifies/recommends modifications to the plan to help ensure a successful discharge/transition. Assures patient is discharged/transitioned to the appropriate level of care that is agreeable to the patient/family or guardian, etc. Assures that patients with identified risk for…

Registered Nurse, Care Manager