Case Management RN

JOB TITLE: RN Case Manager

DEPARTMENT: Case Management

REPORTS TO: Director

JOB SUMMARY: The Case Manager is responsible for the coordination and efficient utilization of health care resources for the provision of quality care for all hospital patients throughout the Continuum of Care. The Case Manager will facilitate clinically appropriate and fiscally responsible patient care through communication with the treating physicians, and all other members of the health care team. The Case Manager assesses and identifies the patient's physical and psychosocial needs, and determines, in conjunction with the physician, established protocols, pathways, and evidence-based medicine tools, health care services, and level of care appropriate for the patient. Management is prospective through the admission process, concurrent during hospitalization and retrospective through review of individual cases and identification of trends and patterns. The Case Manager communicates with payer source(s) to ensure appropriate reimbursement at appropriate level(s) of care. OSHA Blood borne Pathogens Class I.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

A. Utilizes Case Management process to include psychosocial assessment, planning, implementation, coordination, monitoring, evaluation of each patient.

B. Coordinates appropriate community and health agency referrals to include all alternate levels of care (Swing Bed, SNF, Inpatient Rehab, LTAC, Home Health, and other as needed).

C. Appropriately reports potential adult/elder/child abuse cases to legal agencies.

D. Ensures that initial and continued stay case management assessments include the use of InterQual/MCG criteria. Seeks clarification from staff, ancillary departments and attending physicians when necessary. All Utilization Review (UR) is documented in patient medical record.

E. Designs and implements a specific discharge plan on appropriate patients as soon as is possible after patient's admission. Collaborates with physicians, social workers, nurses, and other multidisciplinary team members as appropriate.

F. Maintains timely response to requests from payers, appropriately escalating any issues. Also - documentation in patient record re: authorizations obtained, delays in authorizations, and other needs requiring payer assistance.

G. Monitors and facilitates patient status changes from Outpatient with Observation services, bedded surgical patients, to Inpatient, OR Inpatient / bedded surgical patients to Outpatient with observation services - will apply current evidence-based medical criteria guidelines to ensure appropriate level of care is assigned to each patient case, notifies patient registration, and provides appropriate notification to patients as required by CMS Conditions of Participation.

H. Monitors and reports variances in provision of cost-effective use of hospital resources and acute hospital days.

I. Addresses barriers to discharge with health care team and ensures initiatives are implemented to provide for patient safety and maximize positive outcomes for patients and the organization.

J. Assures that ongoing documentation is in patient's medical record regarding discharge plan and progress to discharge, including patient's discharge destination.

K. Plans for and participates in team / family / patient conferences thereby providing that collaborative discharge planning and ongoing health care is in alignment with patient's goals and desires.

L. Serves as expert resource regarding correct patient status, that medical necessity for admission has been addressed by physician and provides guidance to health care team regarding reimbursement issues as they arise.

M. Participates in hospital quality improvement - implements initiatives as needed to address challenges.

N. Participates in process improvement activities related to comprehensive documentation, ensuring clarity and content that reflect medical necessity of services in medical record, and facilitates by ensuring clear and concise medical documentation - collaboration with CDI personnel accurate coding at discharge.

OTHER SIGNIFICANT REQUIREMENTS:

• Participates on hospital committees as appropriate and on request.
• Participates in mandatory on-call coverage on weekends, when necessary.
• Adheres to departmental and hospital policies.
• Accepts other duties as assigned.

JOB QUALIFICATIONS:

A. Education: Bachelor of Nursing

B. Personal job-related skills: strong collaborative skills, strong communication skills, ability to work with physicians and all other members of health care team, must have

C. Licensure, registry or certification: Active RN licensure as Registered Nurse in State of Texas; Current BLS certification; Certification in case management preferred.

D. Experience:

a. Prior Work Experience: Minimum of 5 years acute clinical experience as a Registered Nurse, with two years of acute inpatient case management experience preferred.

b. Technical Training: must have proficient knowledge of computer programs (Office); must be proficient in at least 1 of the following: MCG, InterQual clinical guidelines for utilization review.

E. Physical and Mental Requirements: Able to work at patient bedside, ability to help provide emergent care of patient if needed, maintain strong relationships with community resources

F. Skills/Knowledge/Qualifications:

• Medicare/Medicaid criteria guidelines for hospitalization.
• Managed care contracts/guidelines.
• Knowledge of data-driven decision-making tools and their use.
• Working knowledge of various reimbursement mechanisms, including third party requirements.
• Current working and demonstrated knowledge of InterQual/MCG criteria.
• Possession of critical thinking skills and the ability to analyze and present data.
• Ability to establish and maintain effective working relationships with the patient, families, physicians, and peers.
• Demonstrated ability to operate personal computer programs.
• Provides respectful, courteous, and professional support to all members of the healthcare team.