Case Manager, RN

Overview

Under the general supervision of the case management Director acts as a patient advocate/case manager to hospital clients. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost efficient patient outcomes. Looks for opportunities to reduce cost while ensuring the highest quality of care is maintained.

Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically based case management, discharge planning, and care coordination to facilitate the delivery of cost-effective quality health‑care and assists in the identification of appropriate utilization of resources across the continuum of care. Works collaboratively with interdisciplinary staff internal and external to the organization. Participates in quality improvement and evaluation processes related to the management of patient care.

• Does the initial screening of all elective in patient admissions related to:
  • Level of care
  • Appropriateness of admission (IS-SI)
  • Discharge needs
  • Third party contractual arrangements
  • Appropriate resource utilization
  • Coordinates the pre‑admission screening and education of the identified patient populations
  • Coordinates out-of‑area transfers
  • Documents patients admitted directly through Pre‑Admissions in the laptop system and forwards the information on to the Case Managers as appropriate with discharge planning concerns and the initial discharge‑planning screen

• Develops educational programs (pre/post op surgeries), high risk screening tools, Care‑Maps for the Pre‑Admit phase of identified populations and proactive discharge planning.
• Coordinates OOA/OON Managed Care admissions, as well as meeting criteria and the Level of Care, which is appropriate according to Interqual and Millman & Robertson Guidelines.
• Serves as a source in selecting and assigning the admission types (i.e. In Patients, 23:59, SOS, etc.).
• Interacts with the admitting MD as appropriate involving the Physician Adviser as needed for inappropriate admits/transfers/level of care.
• Oversees that Pre‑Admit TAR's are obtained and the patients payer sources have the appropriate network among the patients health care team (i.e. Case Mgmt, Business Office, Physicians, Social Services, Nurse Manager, etc.).
• Is a clinical resource to admitting department and provides ongoing education on the effective resources of the Pre Admission Case Manager and Quality/Case Management Department to physicians, physician office staff, nursing.
• Maintains identified tracking and data statistics as requested by Commitment to Quality role in Case Management.

• Is aware of and follows all hospital and department process policies and procedures.
• Is knowledgeable of Improvement performance/process improvement (P.I.) methodology.
• Can verbalize knowledge of hospital-wide performance/process improvement activity.
• Offers suggestions for departmental and/or hospital-wide performance/process improvement.
• Knowledge of and participation in the performance/process improvement is a condition of employment.

• As observed by representatives of management, all interactions are conducted in a professional manner.
• Verbal and written feedback from patients, family members/significant others, medical staff, visitors and co‑workers indicates behavior conducive to positive guest relations.
• Consistently exhibits appropriate phone protocol (e.g., answers phones promptly, is courteous, helpful and identifies self and department).
• Consistently contributes to the team effort (e.g., assists co‑workers when need is observed or upon request, offers constructive suggestions rather than complaints).
• Consistently displays cheerful and positive attitude.

• Maintains high productivity and performs efficiently regardless of whether the work volume is high or low.
• Appropriately prioritizes work activities.
• Responds to difficult situations with self‑control and a positive attitude.
• Makes decisions independently and knows when to ask for…