Case Manager

Position Summary

The position provides comprehensive care coordination for patients as assigned and assesses the patients plan of care. The Case Manager is responsible for Length of Stay management and discharge planning. Develops, implements, monitors and documents the utilization of resources and progress of the patient through their care, advocating and facilitating options and services to meet the patients health care needs. Interacts extensively with the care teams to support the clinical roadmap.

Position Duties

• Coordination of Care
• Manages a defined service line patient population to achieve optimal discharge and continuity of care outcomes in a manner that promotes sound financial stewardship and patient-family advocacy.
• Establishes estimated Length of Stay via MCG criteria and tools, Completes an initial screen of all patients on admission (not to exceed within 24 hours of admission) utilizing MCG criteria to identify needs related to care coordination and/or discharge planning.
• Leveraging MCG and other evidence-based guidelines, coordinates development and implementation of a comprehensive discharge care plan in collaboration with the clinical care team.
• Ensures plan of care is in place with all team members. Proactively collaborates with members of the interdisciplinary clinical care team to define and document a clear and comprehensive treatment plan, including post-discharge needs.
• Identifies and facilitates resolution of variances in the plan of care that may impact length of stay.
• Facilitates referrals to other disciplines, and monitors for appropriate follow-up.
• Facilitates and provides on-going communication with patient/family and escalates unresolved barriers to timely discharge to Case Management, Manager or Utilization Management Medical Director, as per department protocols.
• Reviews and analyzes third-party payer denials for in house patients, and communicates to attending physician, Case Management, Manager, Utilization Management Medical Director, and Utilization Management Nurse as per department protocols.
• Cultivates and maintains effective interaction/communication with members of the interdisciplinary care team and proactively engages patient and families in the delivery of care across the continuum of care.
• Reviews the patient daily for appropriate patient status, level of care and goal length of stay per established Case Management daily prioritization protocol, utilizing MCG criteria and communicates goal length of stay to clinical care team, patient and family.
• Keeps patient discharge information current in Case Manager EMR documentation.
• Assesses each patients status and activities daily as appropriate to patient needs.
• Ensures timeliness of care and identifies barriers to transition of care or discharge.
• Participates in interdisciplinary rounds and/or service line rounds with clinical care team.

Regulatory Responsibilities

• Reviews the patient daily (Observation and Inpatient) for appropriate status and meeting admission or discharge criteria.
• Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct ongoing care planning and discharge planning.
• Utilizes MCG guidelines/pathways to determine admission status, level of care, goal length of stay and continued provision of services as evidenced by audit of documentation in EMR.
• Documents avoidable days, extended length of stay, authorizations and denials for medical necessity in SCM and SAM as evidenced by audit.
• Communicates to Utilization Management Nurse data supporting denial appeals, or notification of potential denials.
• Communicates with payers to resolve potential denials.

Working Knowledge

• Provides Medicare/Tricare Rights and Detailed Notice of Discharge to patient and families.
• Transition and Discharge Planning
• Affirms thorough, early and ongoing transition/discharge plans by collaborating with patients, families, payers and providers across the continuum of care.
• Affirms assessing patient for appropriate discharge placement. Identifies presumed discharge location on admission. Consults with social services and other resources as needs or problems are identified.
• Ensures that health care team is proactive in making arrangements for transition/discharge, and ensures that each transition/discharge plan has clear goals that are attainable.
• Ensures that all elements of patients' needs are addressed in the transition/discharge plans.
• Validates that family and patient are aware and understand discharge plan as demonstrated by documentation and feedback.
• Ensures that education and teaching for family and patient to support transition/discharge is begun as quickly as possible with the health care team.
• When appropriate, performs outpatient and clinic care coordination and monitors patients care as they transition between inpatient and outpatient service.
• Provides excellent customer service
• Ensures that all elements of patients' needs are addressed in the transition/discharge plans.
• Keeps families and patients involved and informed as demonstrated by feedback.
• Facilitates and provides on-going communication with patient/family and interdisciplinary staff to identify and resolve potential barriers to discharge
• Communicates with payers to resolve potential denials.
• Leadership care coordination
• Demonstrates strong, consistent clear communication and serves as central point of information informing all team members, including physicians, on patient status and goal length of stay.
• Keeps families and patients involved and informed as demonstrated by feedback.
• Cultivates and maintains effective interaction/communication with members of the medical staff, nursing staff, social workers, Utilization Management team and families to drive the care coordination process and to facilitate continuity of patient care.

Qualifications

• Education: Bachelors degree in Nursing or a combination of Associate degree in Nursing coupled with 3 years clinical experience.
• Experience: Minimum of (1) year of broad clinical experience. Care coordination, case management, discharge planning and utilization review experience preferred.
• Special Skills: Bilingual (Spanish) Preferred, MCG criteria knowledge Preferred, Excellent communication skills, both verbal and written. Required, Effective critical thinking skills and ability to anticipate patient discharge needs. Required, Moderate to expert computer skills Required, Effective decision-making /problem-solving skills, demonstration of creativity in problem-solving, influential leadership skill. Required