Clinical Resource Manager

About the Role

Provides hospital case management/utilization review and discharge planning, collaboratively determining level of care needs beyond acute care. Offers decision support to patients, families, and physicians, manages expectations, and ensures smooth transitions to the next level of care and services. Coordinates the integration of social services into patient care as appropriate and oversees hospital activities related to case management, utilization review, and discharge planning. Adheres to departmental goals, objectives, standards of practice, and policies while ensuring quality patient care and regulatory compliance.

Incorporates real-time contacts with physicians, nursing, and ancillary caregivers to establish specific treatment, cost, and transition targets, facilitating transition planning to achieve quality clinical and cost outcomes.

Requirements

• Active RN license, as defined by the primary work state (Idaho or Oregon).
• IDAHO ONLY: If a nurse moves to Idaho from another compact state, they must apply for licensure by endorsement and update their primary state of residence to Idaho within 60 days of hire.
• All colleagues must provide licensure or proof of application for secondary state within 90 days of hire.
• BSN required; master's degree preferred.
• Minimum of 2 years of varied hospital clinical experience.
• Experience in case management, home health, and/or the insurance industry preferred.

Responsibilities

• Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions.
• Demonstrates knowledge and skills to competently care for all assigned age groups (Neonate, Child, Adolescent, Adult, Geriatric as applicable).
• Revenue Management: Ensures accuracy in documenting services and supplies provided to patients.
• Coordinates integration of social services/case management functions into patient care, discharge, and home planning with other departments, external organizations, agencies, and healthcare facilities.
• Completes screening/assessment of physician-assigned cases to determine medical necessity, status, and transition needs; reassesses and modifies as needed.
• Conducts concurrent medical record reviews using established criteria to determine correct level of care for acute patients.
• Assists physicians with completing transfer and discharge orders.
• Maintains knowledge of federal, state, and private agency review requirements and educates healthcare team members on regulatory standards.
• Promotes effective and efficient utilization of clinical resources from admission to discharge.
• Initiates and presents "denial letters" as appropriate.
• Completes PASRRs for admission to skilled nursing facilities.
• Delivers Condition Code 44 letters to patients and educates them on Medicare benefits.
• Researches and locates resources for patients, such as financial assistance for medications, Medicaid pending processes, and equipment procurement with limited funding.
• Communicates with physicians regularly throughout hospitalization and develops effective working relationships to maintain appropriate cost, case management, and patient outcomes.
• Introduces self to patients and families, explaining the clinical resource manager role and contact process.
• Serves as a patient advocate and enhances collaborative relationships to support informed decision-making.
• Participates in multidisciplinary patient care rounds/conferences to review treatment goals, optimize resource utilization, and identify post-hospital needs.
• Utilizes physician advisor referrals as appropriate.
• Reviews 30-day readmissions and adheres to established processes.
• Follows patient choice policy and documents assessment of primary/backup plans along with communications to patients, families, and care teams.
• Documents interventions in Power Chart.
• Actively participates in department staff meetings and sub-teams.
• Ensures discharge planning compliance with Medicare Conditions of Participation, regulations, and Joint Commission standards.

Benefits

Saint Alphonsus Health System offers competitive compensation with a full benefits package and opportunities for growth within SAHS and Trinity Health.