Case Manager-Rn

About the Role

Ensures collaboration among multiple parties: the patient, family, and the multi-disciplinary team (internal and external stakeholders), which may include the payer, to facilitate and coordinate services specific to the patients' needs during an episode of care and/or post-hospitalization. All case manager activities will be client-centric, performed in a proactive manner, require ongoing assessment of needs, evaluation of resources, knowledge of associated costs, and education as indicated. The case manager is responsible for presenting options in an unbiased fashion to all involved parties and in compliance with HIPAA. Empowerment of the patient or healthcare proxy is expected and maintained so an informed decision regarding continued care needs can be made. Advocacy and education are at the heart of all activities with the basic goal focused on providing the best clinical outcomes possible for the patient through evidence-based practice.

Responsibilities

• Discharge Planning: An ongoing process requiring daily or as-indicated evaluation and re-evaluation of the patient’s needs via interview and chart review. Discharge planning starts at admission, with a tentative discharge plan documented in the patient’s medical record within 24-48 hours. Assessment includes reviewing current and prior functioning, psycho-social dynamics, and support systems. The plan is developed in collaboration with the multi-disciplinary team, patient, and/or family, addressing barriers to facilitate a smooth transition to the next level of care. Insurance benefits are reviewed to ensure appropriate next-level care services, including co-pays, deductibles, and potential cost-related barriers. Determine patient needs and resources within 24 hours of admission (or 48 hours in extenuating circumstances). Consider patient and family healthcare literacy, education, and socio-economic status to ensure understandable and usable information. Coordinate and collaborate with the patient or decision-maker to provide information on financial resources, insurance limitations, and tentative discharge plans. Familiarize the patient with the case manager’s role, hospitalization expectations, and potential care options (e.g., rehabilitation, nursing home, personal care, hospice, home care, community resources). Provide an "options" list of providers per regulations and expedite next-level care decisions. Facilitate a collaborative environment with internal and external stakeholders (physicians, therapists, nurses, payers, outside resources, patient, and family) to achieve the best outcome. Advocate for patients unable to advocate for themselves, including mediation and facilitation with the multi-disciplinary team or family. Serve as a resource to resolve obstacles impeding high-quality, cost-effective care. Coordinate post-hospitalization care, including discussions with primary care physicians or referrals to community resources (e.g., WIC, food stamps, HRSA). Delegate discharge needs to healthcare team members as appropriate. Coordinate plans for post-discharge care with a focus on age-specific or special population needs. Complete requisite documentation in Allscripts and Meditech regarding discharge plans, discussions, and compliance with regulatory guidelines. Participate in readmission assessment and identification activities as outlined in department policies. Collaborate in the development and implementation of treatment plans and secure authorization for additional patient services as required. Verify insurance benefits for post-discharge care planning.
• Implementation and Facilitation of Care: Act proactively to address real and potential issues in the development and implementation of the plan of care. Document activities and discussions in the patient’s medical record, including outreach to external stakeholders (e.g., primary care providers) to overcome barriers and achieve successful outcomes. Verify benefits and secure authorizations from payers as indicated. Facilitate necessary community resources and advocate for patients, ensuring they or their healthcare proxy can make informed decisions. Mediate conflicts between physicians, consultants, and families to ensure smooth transitions. Identify potential barriers to a safe discharge during the initial assessment and re-evaluate the discharge plan daily, documenting in Allscripts and Meditech at least every other day. Review current and past records to identify contributing factors to illness or re-hospitalization. Complete due diligence to identify additional assessments beyond the initial evaluation. Respect and support the patient’s right to self-determination and freedom of choice. Objectively present all options, risks, benefits, and information to assist in informed decision-making. Maintain collegial and collaborative relationships throughout the care continuum. Provide outreach to community providers as needed to ensure optimal patient outcomes. Proactively consult and collaborate with internal and external stakeholders (e.g., during rounds, phone calls to practitioners or payers, requesting consults with disciplines like physical therapy, nutrition, or psychiatry). Document all activities and efforts to ensure a safe discharge in Allscripts and Meditech, including patient/healthcare proxy choices, referrals, final disposition, and other notes. Respond to requests for consults and educational materials (e.g., elder law, advance directives) within one working day per department standards. Maintain working knowledge of relevant laws (e.g., Pennsylvania Mental Health Procedure Act, Child Protective Services Laws, Patient Self-Determination Act, OBRA, Older Americans Act). Identify patients who may lack capacity to make informed decisions and request evaluations as needed. Consult and notify managers and Risk Management if capacity is in question or no Power of Attorney is identified. Assist with guardianship issues as required. Maintain accountability for assigned caseload.
• Data Collection: Participate in collecting information for quality improvement activities and risk management, reporting through appropriate committee structures. Maintain knowledge of current case management theory, practice, quality initiatives, and regulatory requirements. Stay informed about clinical practice guideline development, utilization, and measurement. Participate in prioritizing and developing practice guidelines and committees focused on improving patient care and outcomes. Monitor care practices in relation to accepted standards and regulatory entities (state and federal). Identify and act on variances, including notifying supervisors. Collect and report information on quality improvement activities and risk issues through appropriate channels.
• Behavioral Expectations: Exhibit consistent professional conduct in interactions with patients, families, medical staff, payers, and peers while respecting HIPAA requirements. Take ownership for errors and implement immediate corrective actions. Maintain high standards of professional conduct and demonstrate respect for all stakeholders. Facilitate open communication and work to achieve positive, productive relationships with internal and external partners.