Case Management Nurse

Overview

The Case Manager has a day-to-day responsibility for assessing the medical necessity of patient admissions, and continued stays, based on the clinical documentation in the Electronic Health Record (EHR) in accordance with Milliman Care Guidelines (MCG). The Case Manager assists in coordination of care among multidisciplinary team members such as Medical Attending’s, Residents, Interns, Specialists, Social Workers, Nursing, Dietary, Finance, and Clerical staff. Case managers identify triggers to re-admissions and needed community/social/financial support to maintain appropriate and safe discharges related to ongoing medical management of patient care needs. The goals of the Case Management services are to identify Physician and staff documentation opportunities to support Quality and Pay for Performance indicators and execute prudent and sequential care by bringing about awareness to all treatment team members on length of stay reduction, and advocacy for compliance to plan of care.

Responsibilities

• Case Managers are expected to have strong clinical backgrounds, and advocate for safe, timely adherence to executing the patient plan of care.
• Job training is available in addition to meeting the core qualifications for this position.
• Performs face-to-face visits with patients that need assessment of physical, mental, and emotional barriers that prohibit self-care, prompt medical management assistance in the community, and initiation of referrals to social work by using nursing clinical judgment
• An interdisciplinary care team member responsible for daily EHR review of patient’s medical necessity (severity of illness and intensity of service); either in bedside rounds, or Interdisciplinary team rounds
• Collaborate with social workers on identification on any social determinants of health domains, that could impede patients’ health outcomes
• Functions as a liaison between Physicians and Physician Advisors
• Demonstrates the ability to correlate medical necessity (severity of illness and intensity of service) in achieving financial and quality care outcomes
• Makes appropriate referral to financial services prior to discharge
• Communicates with Attending Physicians on admission guidelines
• Provides real time interventions to prevent delays and ensure compliance and revenue integrity with health care regulations
• Informs treatment team members of recommended EHR documentation needed based on Milliman Care Guidelines for approval of admission, transfer, length of stay, and safe discharge planning
• Affords appropriate referrals to home care and wound vac services
• Completes PRI’s and documents all activities in EPIC
• Communicates with Nursing staff the patients discharge plan
• Advocates for the patient/family with other health care disciplines and community agencies to facilitate the patient receiving the appropriate resources in the community
• Mandated reported of suspected abuse in all patient populations (domestic violence, elder, child abuse, etc.)

Qualifications

• Education: Bachelor's degree in Nursing (BSN), required
• Experience: Minimum three (3) years clinical experience in one or more of the following: Acute care, Medical-Surgical, Intensive Care, Emergency Department, Community Nursing (Home Care)
• Licenses/Certifications: Current New York State Registered Nurse licensure, required; Basic Life Support (BLS) certification, required; Advanced Cardiovascular Life Support (ACLS) certification, required; Patient Review Instrument (PRI) certification, required; Pediatric Advanced Life Support (PALS) certificastion, preferred; Case Manager Certification (CCM), preferred
• Knowledge, Skills And Abilities: Knowledge of Federal, State and JCAHO guidelines for utilization review, discharge planning/quality assurance/infection control