Case Manager

About the Role

Case Manager coordinates care and service of selected patients across the health care continuum. Promotes effective utilization of resources and the highest quality of care for optimal clinical and resource outcomes. Ensures appropriate lengths of stay based on medical necessity. Assesses and implements effective discharge planning through identification of appropriate services and facilities across the continuum of care. Assumes a leadership and communication role with the patient/family, interdisciplinary team members, and providers of appropriate services across the continuum. Provides ongoing monitoring and evaluation of the plan across the continuum as appropriate. Integrates evidence-based clinical and preventative guidelines in the development of patient-centered tools to assist patients in decision-making that benefits their optimal health. Provides targeted interventions to avoid unnecessary hospitalizations and emergency room visits.

Responsibilities

• Providing interpretation and support for those who are awaiting placement in a nursing home or physical rehabilitation.
• Completion of Referrals, including PRI.
• Provide appropriate resources and referrals for treatment of alcohol abuse, drug abuse, child abuse, domestic violence and other mental health issues.
• Reviews incoming referrals for swing bed placement.
• Supports Mountainside Residential Care Center as needed, including PRI's.
• Discharge planning, implementation, and serve as a liaison between hospital and all community agencies and institutions interested in the well-being of patients.
• Helping patients and families get information and services to meet special needs not provided by the hospital or needed after discharge in an institutional or non-institutional setting.
• Locating community and other local resources available to patients in the hospital and after discharge.
• Developing and implementing appropriate and well-coordinated referral procedures with these resources.
• Following through on referrals to ensure necessary treatment plans have been implemented.
• Swing Bed Coordinator: interprets, supports, and recommends Swing Bed policies and procedures.
• Covers UMR and attends UMR meetings.
• Maintains compliance with social services standards, hospital policies and procedures, and regulatory agency requirements.
• Utilization Review (UR): Reviews all acute/swing admission medical records.
• UR: Reports concerns regarding admissions and continued stay to Utilization Review Chairperson and Medical Director.
• UR: Prepares monthly statistical report for monthly review at the UR Committee meeting.
• UR: Provides clinical reviews to medical insurance companies as requested.
• UR: Collaborates with the Health Information Manager to appeal insurance denials, setting up peer-to-peer if needed.
• UR: Reports UR statistics to Board Quality quarterly.
• Call all patients post-hospital stay to review understanding of discharge instructions and assist with follow-up PCP appointments, medications, if needed.
• Other duties as assigned.

Requirements

• Two (2) years hospital-based experience preferred.
• One (1) year QA/UR or Case Management experience preferred.
• Current knowledge of Federal and State regulations.

Qualifications

• RN, graduate of an accredited school of Nursing or CSW preferred; or B.A. or B.S. in related field (meets requirements of NYS Department of Health).
• PRI certification required.

Skills

• Excellent verbal and written communication skills.
• Strong organizational skills.
• Self-motivated.
• Able to make sound clinical decisions.
• Knowledgeable about community resources.
• Able to use/enhance coaching skills over a varied patient population.
• Able to share coaching knowledge and act as a role model for staff.
• Able to delegate.
• Work in an organized fashion.
• Understands the importance of time management relative to meeting patient needs efficiently and effectively.
• Able to identify and intervene when concerns arise.
• Engages with team members to promote cohesive workflow.