Complex Inpatient Case Manager

About the role

This role provides comprehensive care management services focusing on patients with the highest complex medical and/or psychosocial needs. This discharge planning specialist carries a caseload of complex patients identified by length of stay, dollar, or time intensive discharge planning outlier designation and serves as a resource for staff.

Responsibilities

• Perform thorough patient assessments, identifying critical health issues and implement targeted interventions and patient-family centered care plans to achieve optimal health outcomes.
• Collaborate and negotiate effectively with clinically complex patients, family and the clinical team while striving to achieve patient and organizational goals regarding care needs, choices, and satisfaction during discharge planning and care transitions.
• Aggregate, analyze, interpret and report data on patient outcomes and resource utilization.
• Facilitate reporting of utilization monitoring and review activities to relevant committees and stakeholders.
• Offer continuity of care and discharge planning services for clinically complex patients compliant with regulatory standards.
• Participate in the communication processes to facilitate smooth transitions for patients, families, and staff during patient transfers.
• Provide advanced clinical guidance and mentorship to frontline care management team members fostering a culture of excellence and continuous improvement.
• Lead initiatives aimed at enhancing care quality, patient safety, and overall healthcare delivery efficiency.
• Advocate for patients and their families to ensure their voices are heard and their needs are met within the healthcare system while optimizing the utilization of hospital resources ensuring cost-effective care delivery and adherence to regulatory guidelines.
• Initiate internal and external referrals to assure timely progression of care and transitions for clinically complex patients.
• Document discharge planning interventions and utilization review activity according to department and organization standards in a timely manner.
• Perform and document accurate and timely concurrent and retrospective reviews for clinically complex patients based on approved criteria by department standards.
• Communicate effectively with the healthcare team regarding clinically complex patients.
• Partner with Social Work and unlicensed support personnel to effectively establish and implement a safe plan of care.
• Serve as a leader of the multidisciplinary rounds and work closely with clinical team members, hospital departments and ancillary services to identify and resolve barriers to discharge, expedite care delivery to avoid delays in timely service provision, and implement and report on care coordination and discharge planning.
• Collaborate and lead discussions with managers, physicians, medical directors, advisory groups, and treatment teams for issues related to physician practices and best practices for the patient care plans.
• Refer cases to physician advisors as needed to ensure efficient progression of care, accurate status, and compliance with regulatory guidelines.
• Maintain knowledge of healthcare regulations, reimbursement issues, impact on length of stay and community-based resources.
• Deliver CMS regulatory notices within CMS established timeframes, as appropriate based on-site guidelines.
• Develop and maintain productive relationships with community-based agencies, particularly those serving clinically complex patients.
• Represent Advocate Health in a positive manner, working collaboratively, internally and externally to meet patient and family needs.
• Collaborate with Advocate Health Ambulatory Care Management and Continuing Health to achieve mutual goals and outcomes.
• Demonstrate knowledge and skills necessary to provide care appropriate to the age of the patients served.

Requirements

• Licensure, Registration, And/or Certification Required:
  • Registered Nurse License issued by the State in which the team member practices.
  • Nurse Case Management (RN-BC) certification issued by the American Nurses Credentialing Center (ANCC) needs to be obtained within two (2) years.
  • Care Manager Certified (CMC) certification issued by the National Academy of Certified Care Managers (NACCM) needs to be obtained within 2 years.
  • Accredited Care Manager (ACM) certification issued by the American Case Management Association (ACMA) needs to be obtained within 2 years.
• Education Required:
  • Bachelor’s degree in nursing.
• Experience Required:
  • 2 years of clinical nursing experience and 3 years of care management experience.

Qualifications

• Ability to prioritize and organize work.
• Effective communication skills.
• Utilization of critical thinking and timely decision making.
• Basic utilization of MS Office products.
• Knowledge of Medicare A and B guidelines.
• Knowledge of managed care program requirements/implications.
• Ability to apply elements of utilization management programs.

Skills

• Physical Requirements And Working Conditions:
• Must be able to sit up to approximately 50 percent of the workday; stand and walk for the equivalent of several blocks at a time.
• Must lift up to 10 lbs. continuously, up to 20 lbs. frequently, and up to 50 lbs. occasionally.
• Manual dexterity required for operation computer and calculator.
• Visual acuity required for facilitating review of written documents/computer screens, medical records, and to record information accurately.
• Clear verbal communications and hearing acuity required for receiving instructions and converse on standard telephone.
• Functional speech and hearing to allow for effective communication of instructions and conversation over the telephone.
• Exposed to normal office environment; including usual hazards related to operating electrical equipment.
• Operates all equipment necessary to perform the job.