Case Manager - Registered Nurse

About the role

Performs a variety of duties and applies utilization and case management techniques to determine the most efficient use of resources to facilitate a patient's progression of care and the provision of appropriate, cost effective and quality health care. Works in a team model with social work in assigned patient care areas to address patient discharge needs. Provides leadership in the integration of utilization and case management principles.

Responsibilities

• Reviews assigned patients for medical necessity, utilization management, and appropriateness of setting for continued hospitalization.
• Initiates problem-solving techniques to prevent over and/or under utilization.
• Facilitates and coordinates the progression of patient care to optimize throughput and the utilization of resources to support continuous quality and cost of care efforts.
• Liaisons between utilization management team, third party payers, and the treatment team regarding the identified treatment plan in accordance with contractual guidelines and System policy.
• Assists the patient care team with the identification and coordination of alternative treatment settings to provide appropriate care, maintain quality of care, and reduce cost.
• Identifies conditions which require case management across the care continuum.
• Collaborates with members of the patient care team to identify interdisciplinary needs
• Collaborates with care management across the system to effectively transition patient care and support value-based care initiatives.
• Completes case management patient assessment, identifies needs, develops a discharge plan, and coordinates discharge needs (DME, Home Health, IV antibiotics, etc.) in collaboration with patients, families, and care team.
• Assists with the collection and analysis of utilization patterns, length of stay, readmissions, avoidable days, and denied cases.
• Brings known or suspected problems of under-, over-, or inappropriate utilization of resources to the