The Case Manager is a professional Registered Nurse with strong clinical knowledge and leadership skills who works under the supervision of the Manager. Collaborates with the patient (all developmental stages), family, physician and interdisciplinary team and payer to plan, organize, coordinate and monitor the provision of cost-effective care in the most clinically appropriate setting, ensuring quality health care services and resources needed to promote optimal outcomes (clinical, functional, financial, satisfaction).
1. Assesses the health status of patients assigned to caseload including data from history and physical assessments, interview with patient/family to determine care needs related to the medical diagnosis, treatment options, financial resources, educational needs, psychosocial needs and discharge planning.
2. Utilizes developmentally appropriate medical necessity criteria to perform admission and continued stay review in order to determine the appropriateness and medical necessity for hospital care and patient status. Issues Admission and Continued Stay Denial Letter as appropriate.
3. Assists the physicians in identifying alternatives to admission for cases that do not require acute care.
4. Educates physicians to insure compliance with the Utilization Management Plan for the hospital.
5. Refers cases not meeting defined level of care criteria to the Attending Physician for review and intervention when necessary. Consults Physician Advisor when appropriate.
6. Makes daily patient/family rounds, maintaining communication with physicians, patient care providers, and other team members regarding treatment plans in order to ascertain appropriate level of care, coordinate timely delivery of services, assist staff in identifying and addressing the learning needs of patients and families, and identify potential quality of care issues and refer these to appropriate management staff.
7. Assists staff in clinical decision making and priority setting to ensure an optimal hospital length of stay
8. Coordinates care for a defined patient population to assure optimal outcomes including appropriate LOS, cost containment, and customer satisfaction.
9. Educates the patient/family, and care providers throughout the continuum of care regarding the care expectations for the patient population.
10. In partnership with Utilization Management Team maintains awareness of current reimbursement issues as they relate to the patient population.
11. In collaboration with the health care team, coordinates discharge services, educates patient/family regarding coverage of discharge services and maintains compliance in arranging services.
12. Participates in performance improvement activities based on the patient population by identifying barriers to care, systems and process issues, and contributing to data collection and analysis for improvement plans.
13. Develops collaborative relationships with other departments, entities, and external health care agencies to facilitate and support quality of care.
14. Demonstrates strong communication skills that are effective in working with a variety of persons, including the patient, public, coworkers, guests, payers, outside agencies and medical staff.
15. Acts as a clinical/educational resource for patients, families, interdisciplinary team members and payers.
16. Organizes and performs work responsibilities effectively and efficiently.
* Registered Nurse
* Cert Case Management
* Associate Degree
Experience: Minimum of 5 years experience as an RN required. Must be able to demonstrate expertise in a clinical specialty for defined patient population. Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
Performs other duties as assigned.
Individual will possess commensurate combination of education, experience and qualifications.