CASE MANAGER

Job Summary:

The Case Managers are experienced Registered Nurses who interact with the patient, families, physicians and other members of the

interdisciplinary team to facilitate quality and cost effective care. An essential component to all roles includes the evaluation of medical

necessity and intensity of service of each admission to arrive at decisions regarding medical appropriateness for the requested level of

care. Communicates with the various payers/insurance companies to authorize services and ensure appropriate reimbursement to the

facility. Actively promotes collaboration among all interdisciplinary care providers, including physicians to effectively identify needs for

continued inpatient care or appropriate alternate levels of care. There is coordination to affect an appropriate discharge plan with the

Case Managers ensuring arrangements of placement/services upon discharge. Assist to identify and make efforts to correct delays in

services, fragmentation of care and gaps in communication. Patient outcome monitoring and participation in continuous performance

improvement are also requirements in this role.

Education

Minimum:

Graduate of a Registered Nurse Program

Preferred:

Bachelor Degree in Nursing

Registration/Certification/Licensure:

Current PA RN license

Preferred: Healthcare Provider CPR

Experience

Minimum:

Three years recent clinical experience.

Preferred:

Managed care or previous Case Management/Utilization Review experience.

Other Requirements:

Excellent communication skills and skills in customer service. Demonstrates leadership ability. Commitment to the delivery of quality

patient care with the ability to develop and maintain effective, professional relationships with all members of the health care team.

Status:

Non-Exempt

Physical Requirements:

The following frequency definitions apply to all Physical Requirements unless otherwise noted:

Occasional: (0-1/3 of day , 0 - 2.5 hrs/day, 1 - 4 reps/hr)

Frequent: (1/3 -2/3 of day , 2.5 - 5.5 hrs/day, 5 -24 reps/hr)

Constant: (> 2/3rd of day , > 5.5 hrs/day, > 24 reps/hr)

NOTE: An asterisk (*) indicates that the item is an essential function.

Non-Material Handling

Standing* - Remaining on ones feet in an upright position remaining stationary. -FREQUENT

Walking* - Remaining upright on ones feet, and moving about. -FREQUENT

Sitting * - Body remains in a seated position. -FREQUENT

Stooping - To bend the body downward and forward by bending the spine at the waist. - OCCASIONAL

Bending - To flex the upper body forward. - OCCASIONAL

Twisting - To rotate the upper body forward. - OCCASIONAL

Climbing - To move the body in any direction on equipment or structures that do not include stairs or ladders. - N/A

Ladders - To ascend and descend ladders. - N/A

Stairs - To ascend and descend stairs. - FREQUENT

Kneeling - To move the body downwards and come to rest on both hands and both knees - OCCASIONAL

Squatting - To move the body downwards by bending both knees. - OCCASIONAL

Crouching - To bend the body forward and downward by bending the spine and the legs. - OCCASIONAL

Crawling - To move the body forward or backwards on hands and knees. - N/A

Reaching Horizontal - To extend the arms and hands outward, remaining under shoulder height - OCCASIONAL

Reaching Overhead - To extend the arms and hands up and out over shoulder height. - OCCASIONAL

Grasping - Using functional gripping of the hand to handle an object. - CONSTANT

Finger Manipulation - To manipulate objects with the use of fingers. - CONSTANT

Seeing - Using visual feedback to accomplish a task or activity. - CONSTANT

Hearing - Using sound feedback to accomplish a task or activity - CONSTANT

Repetitive Upper Extremity Use - Using the arms and/or hands continuously or more than 2/3 of the total time. - CONSTANT

Repetitive Lower Extremity Use - Using the legs and/or feet continuously or more than 2/3 of the total time. - CONSTANT

Material Handling

Pushing* - To exert a force upon an object in order to move it in a certain direction. Pushing refers to moving an object away from the

person.

CONSTANT

Up to 20#

Pulling* - To exert a force upon an object in order to move it in a certain direction. Pulling refers to moving an object towards the

person.

CONSTANT

Up to 20#

Lift - Floor to waist

CONSTANT

Up to 20#

Lift - Waist to shoulder

CONSTANT

Up to 20#

Lift - Shoulder to overhead

CONSTANT

Up to 20#

Carrying - To transport an object or article using the arms or hands (> 10 feet)

CONSTANT

Up to 20#

Environmental Factors

Working alone - OCCASIONAL

Working in cramped quarters - FREQUENT

Constant interruptions * - CONSTANT

Working with hands in water - N/A

Use of power tools - N/A

Working on ladders/scaffolding - N/A

Exposure to vibration - N/A

Exposure to dust - N/A

Exposure to noise (constant) - N/A

Exposure to electrical energy (outlets, etc) - N/A

Exposure to termperature changes (heat, cold, humidity), that require special clothing - N/A

Exposure to slippery walking surfaces - N/A

Exposure to solvents, grease, oils - N/A

Exposure to radiant energy, i.e. computer terminal (more than 4 hours per shift) * - CONSTANT

Working with bloodborne pathogens - N/A

Cardiovascular Energy Requirements - Physical Demand

Physical

Demand

Met

Level

Examples of similar activity intensity

Sedentary to

Light

0 - 3.5 Light house cleaning, washing dishes, serving food, food shopping, sitting, standing, computer work.

Medium 3.6 - 6.3

House work (mopping, scrubbing), health club exercising, treadmill work, stretching, yoga, walk/run-play

with children, aerobic class, dancing, carrying bucket/wood, auto body repair, shoveling snow, golf

(carrying clubs).

Heavy to Very

Heavy

> 6.4

Calisthenics (push up, pull up, sit up, vigorous effort), carrying groceries upstairs, shoveling coal, bailing

hay, fire fighting, sawing by hand, splitting wood.

As relates to this position:

Sedentary to Light - CONSTANT

Medium - N/A

Heavy to Very Heavy - N/A

. Specific Job Responsibilities (Essential Functions):

1. Performs admission as well as continued stay review of designated cases through established decision support criteria (Interqual) accurately

identifying Severity of Illness/Intensity of Service to determine appropriateness of admission and ensure appropriate reimbursement. Focuses on

Observation cases to determine appropriate action/follow up necessary in relationship to medical necessity; i.e. discharge/transition to inpatient

status. Demonstrates understanding and efficiency in physician referrals/tasking to EHR.

2. Provides clear documentation of selected medical necessity criteria as well as interventions and obtained authorizations. Demonstrates the ability

to navigate the Navinet On Line Highmark process, the Allscripts case management module, Meditech and EMR.

3. Understands and applies the many reimbursement strategies of the various payers and makes appropriate decisions relevant to this information

(i.e. per diem/DRG, case Rate, observation, etc). Completes all required authorizations/pre-certifications to ensure appropriate reimbursement to

the facility.

4. Serves as an organizational collaborator for the patient to promote appropriate, efficient quality care. Collaborates with the Social Worker and

health care team to ensure timely discharge planning; demonstrating efficiency in arranging for patient Post Discharge Needs: home infusion

therapy, medications, DME, placement, transportation etc.

5. Remains knowledgeable and participates in ongoing performance improvement activities within the department as well as on an organizational

level; CoP (Conditions of Participation); MEIM, Freedom of Choice; Delay Days, LOS/Readmission Reduction initiatives, HF clinic referrals, identifying

barriers to discharge, fragmentation in patient care, etc.

II. Organizational Responsibilities:

1. Completed mandatory education, annual competencies and department specific education within established timeframes.

2. Completed annual employee health requirements within established timeframes.

3. Maintained license/certification, registration in good standing throughout fiscal year.

4. Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self. Identifies and

works to reduce potentially unsafe patient care or other safety practices.

5. Adheres to regulatory agency requirements, survey process and compliance.