Case Manager Cardiovascular

Responsibilities:

• To perform psychosocial and discharge screening assessments, provide clinical counseling, develop and implement a safe plan for discharge with appropriate referrals to other health care team members, community agencies / resources and after care facilities, as well as be an advocate to the client/families and significant others served by Doylestown Hospital. · Assess patient for discharge needs within 24 hours of admission or within one business day. · Review the medical record. Meet with the patient and/or family / significant others. · Respond to requests for consults in a timely fashion in accordance with established standards. (within one business day) · Collaborate with other involved health care team members and community agencies. · Work with patients, significant others and family to assess, identify, and intervene with psychosocial issues related to illness, hospitalization, recovery, and adjustment to post hospital care needs. · Intervene appropriately with individual patients, discuss their views, feelings and needs in order to improve functioning, enhance insight and promote effective coping. · Meet with pre-admission patients who have scheduled surgeries/procedures for pre-op patient education and to assess DCP needs, social support and discuss options for rehabilitation or other aftercare needs, if appropriate. · Intervene with patients (and families) being considered for rehabilitation, including evaluation, assessment, education, collaboration, and coordination and preparing the patient for transfer to the next level of care. · Assist patients / families with arrangements for discharge by providing options and information on rehabilitation facilities, nursing homes, personal care facilities, hospice services, home care services, home care agencies, and community resources. · Obtain pre-certification / authorizations for subsequent level of care (inpatient, subacute, skilled, psychiatric inpatient and outpatient, substance abuse, hospice) from insurers etc. · Demonstrates the ability to relate to specific age groups and is knowledgeable of age specific developmental tasks/challenges and issues related to each age group (i.e. adullts, geriatrics) · Provide counseling and referrals for cases involving suspected or confirmed domestic, sexual, or elder abuse. · Inform patient / family of, and support and advocate for patient rights, including, but not limited to the following: the right for self-determination, the right to an informed process in decision making, the right to direct decisions pertaining to their healthcare, including the right to refuse treatment or withdraw treatment, the right to formulate an advanced directive and the right for freedom of choice in selecting a provider of health care services. · Respect and support the patient’s Freedom of Choice. Objectively present all options and alternatives with associated risks, benefits, and information to assist the patient in the informed decision making process · Provide resources/assistance to patients with limited income/no insurance. · Assist patient in applying for insurance coverage through Medical Assistance, Patient Financial Assistance Program, Free Clinic and other programs. · Assist patients in securing appropriate benefits and services and offer community resources when available. · Intercede for patients and community members in need of assistance with such issues as transportation problems, medication expenses, housing problems by providing professional assessments and contacting the VIA or other community relief agencies. · Document the initial plan of care along with the goal and regularly update with any changes in the plan. · Assist with Medical Power of Attorney and/or Guardianship issues as the need arises. Coordinate a seamless experience for the acute in-patient, significant others and family members from pre-admission testing through discharge by utilization management (transitioning the patient between levels of care), maintaining communication with payers regarding assessments, outcomes and projected LOS, and developing and implementing a safe discharge plan. · Review for medical necessity within one working day of admission. · Email DH Physician Advisor if documentation does not support medical necessity. · Notify physician to discuss changing the patient’s status as suggested by DH Physician Advisor. · Call in insurance denials to the DH Physician Advisor for a first level peer to peer appeal, if indicated. · If the peer to peer appeal is not overturned, send the case to second level of appeal, if appropriate. · Request and / or respond to consults within one working day of admission. · Verify Insurance coverage with patient and admissions. · Conduct initial clinical admission review with Insurance Company when indicated. · Assess daily for the appropriate level of care for each individual patient and identify on admission any discharge planning needs. · Make daily patient / family rounds maintaining communication with all team members regarding treatment plan and projected length of stay. a. Anticipate discharge plan and discuss patient needs with physician, nursing and other disciplines to coordinate a seamless flow. b. Participate in multi-disciplinary discussions with physical therapy, occupational therapy, speech, nutrition to ensure these areas of patient needs are met prior to discharge. c. Include patient and families in discussions and plans to ensure their consent and understanding of the plan of care. · Demonstrate flexibility and creativity in identifying resources to meet patient / family needs. · Serve as a resource to provide information and direct intervention to resolve problems and / or obstacles that impede the provision of high quality, cost effective care. · Monitor appropriateness of tests / procedures, consultations and treatment plans. Monitor resource utilization. · Communicates with members of the medical and nursing staff to promote optimal utilization of hospital resources · Collaborates with all disciplines to decrease delays in the delivery of services, identify discharge needs, and prevent fragmentation of care. · Review medical record and conduct reviews as needed with insurance company. · Initiate communication with the attending physician to discuss a case that does not meet Interqual criteria. · Communicates any payment denial / payment issue to the Physician Advisor and the Director of Patient Financial Services to plan for possible alternative to the current plan. · Make appropriate and timely decisions to facilitate the discharge process. · Verify insurance benefits in planning for discharge. · Communicate with external Case Managers / Utilization Review regarding clinical aspects of the case for discharge planning, outcomes and projected LOS. · Obtain pre-certification / authorizations, if needed, for home care (visiting nurse, physical/occupational therapy, home health aide, CT Surgery Transitional Care Nurse or social work evaluation), DME needs, and transportation via ambulance from the insurers. · Offer information on support groups and programs that would benefit the patient or family member post hospital stay. Plan, coordinate and facilitate a support group when opportunity arises. · Develop and implement strategies to improve utilization. · Review patient status daily to identify any issues regarding pathway interventions / variances or new discharge needs. · Maintain a working knowledge of case management practices, DRG assignments, Joint Commission on the Accreditation of Health Care Organizations, Medicare, Medical Assistance, Third Party Payers and external review agencies. · Maintains working knowledge of third party payers’ requirements and reimbursement rates for cardiac patient population regarding all aspects of care. · Maintain high standards of professional conduct. Demonstrate respect for medical staff, administration, colleagues, customers, and self. Facilitate open communication and work to achieve positive, productive relationships with internal and external customers. · Demonstrate ability to effectively prioritize work in caseload and job responsibilities. · Demonstrate responsible use of hospital and office resources. · Safeguard and protect confidential information according to established policies and procedures and applicable HIPAA law. Document in the medical record and on departmental worksheets. · Initiate a CM review work sheet on all inpatients in the CVICU and IVU. a. Document relevant diagnostic, therapeutic, lab and clinical data. b. Document the level of care, ICU, Telemetry, Medical Surgical, or Skilled c. Document coordination of continuation of care or DCP. d. Document any other relevant CM activities and date of discharge. e. Document determination received from initial and daily reviews with the insurance company on CM worksheet. f. Document any Physician Advisors calls and suggestions on CM worksheet and Allscripts. g. Keep paper records for 2 years. · Demonstrate accurate assessment and necessary follow-up plans as delineated in the initial CM Assessment. Document regularly in patient care notes to provide appropriate information regarding the plan of care, patient goals, psychosocial circumstances and any revised discharge plan for the patient · Document pre-operative/pre-admission education for cardiovascular surgical patients, TAVR, and, lung patients in Meditech Notes section of the chart. · Document appropriate discharge plan arrangements on the discharge instruction sheet. · Complete Visiting Nurse referrals and contact agency by phone and fax. · Ensure completion of the discharge instruction sheet for cardiac surgical patients. · Document on the cardiovascular surgical patients the anti-coagulant follow-up both on discharge instruction sheet and the MD follow up form which is then forwarded to the physician following the PT/INR results post hospital stay. · Document any complications, medications prescribed at discharge and disposition information on all cardiovascular surgical patients in the Society of Thoracic Surgery database. · Document any denials or downgrade in level of care in Billing Accounts Receivable (BAR). Document level of appeal process requested. · Document any PSR numbers received from Medical Assistance in BAR. · Arrange for and complete forms, paperwork, and data collection in an accurate and timely manner. (VN referral, agency referral, transfers to alternate care setting, MA51, PASSAR, etc) · Document in Meditech and discuss with patient and/or caregiver any paperwork given to patient related to Medicare state regulations (MOON, commercial OBS letter, IMM). · Document and call designated caregiver, if applicable, to discuss discharge plans. Participate in collection, collation, analysis, and plan development and orientation to promote the delivery of efficient, quality services.Evaluate practice of self and others through participation in quality assessment and performance improvement activities. · Participate in departmental and /or hospital committees and teams to work towards continual improvement and excellence. · Maintain departmental statistics in an accurate and timely fashion. · Monitor independent QI studies pertinent to cardiac patient population · Identify and evaluate trends, variations and process barriers which may compromise effective delivery of care and seek appropriate intervention. Coordinate, develop and facilitate quality cardiac education for the person with cardiac disease, the nursing staff, physicians or family members taking care of a cardiac patient at Doylestown Hospital. · Utilizes trends in healthcare, specific to cardiac disease, to assess, collaborate with design, implement and evaluate the education needs for patients with heart disease · Provide pre-operative education to both inpatients and outpatients undergoing cardiac surgery. · Communicates with patients, families, physicians and other health care team members in achieving excellence in cardiac care and education · Serves as a resource to the nursing staff on the cardiac units. · Consult Inpatient and/or Outpatient Education when appropriate for other education needs. (Diabetic education, nutrition, cardiac rehabilitation etc.)

Credentials:

Education or Equivalent Experience: