Inpatient Nurse Case Manager

Department/Unit: Care Management/Social Work

About the Role

The Case Manager is accountable to facilitate the interdisciplinary team to plan, coordinate, implement, and evaluate patient care for an assigned service line across the continuum of care. The Case Manager works proactively with Quality Improvement Teams, patient care standards, and utilization management to coordinate the appropriate use of resources to achieve maximum clinical and financial outcomes. The role involves maintaining quality care and performance improvement through leadership, problem-solving, decision-making, and outcome measurement. The Case Manager serves as a resource for the healthcare team, community, patients, families, and payers by functioning as a clinician, consultant, advocate, and educator.

Responsibilities

• Assists the admission physician and interdisciplinary teams in coordinating care across the continuum, including pre-admission, hospital stay, and post-discharge.
• Proactively monitors patients' clinical progress using patient care standards and evidence-based guidelines to ensure timely, appropriate interventions for optimal outcomes within length-of-stay (LOS) and financial constraints.
• Provides collaborative care management with the primary nurse to assess discharge planning needs, coordinate resources, and evaluate the effectiveness of the discharge plan, beginning at admission.
• Collaborates with the healthcare team to manage care across the continuum, including pre-admission, discharge, post-discharge, LOS planning, and resource utilization.
• Utilizes specialized knowledge and evidence-based guidelines to guide the healthcare team in formulating individualized multidisciplinary care plans covering pre-hospitalization, acute care, discharge education, transition to home, and community resources.
• Facilitates and participates in care conferences for patients with complex needs.
• Facilitates patient and family education and the discharge process to promote continuity of care and optimal outcomes.
• Demonstrates experience in the referral process and use of community resources.
• Reviews admission screening data to clarify diagnosis, establish appropriate LOS, identify potential outliers, and determine admission appropriateness based on institutional standards and evidence-based guidelines.
• Contacts payer sources to confirm/negotiate benefits and provide concurrent reviews.
• Identifies capitated patients to determine appropriate service utilization and coordinates post-hospital care using defined standards.
• Identifies high-risk patients based on clinical and financial criteria for collaboration with patient financial services to problem-solve available resources.
• Ensures appropriate medical/legal documentation is included in patient records.
• Complies with regulations established by third-party payers, including notices of non-coverage, reinstatement, and continued stay.
• Collaborates with the healthcare team to implement strategies reducing LOS and resource consumption while optimizing patient health status.
• Assesses educational needs and provides learning opportunities for healthcare professionals relevant to specific cases and patient care groups.
• Collaborates with case management leadership to compile and report aggregate variances and data for specific patient care services.
• Communicates and analyzes aggregate variances with the healthcare team and develops strategies for variance reduction.

Requirements

• Registered nurse with a current license.
• Bachelor’s degree preferred but not required.
• Minimum of three years of clinical experience in an assigned service.
• Recent experience in case management, utilization management, and/or discharge planning/home care in a high-volume, acute care hospital preferred.
• PRI and Case Management certification preferred.
• Demonstrates effective communication, facilitation, and organizational skills.
• Assertive and creative in problem-solving, critical thinking, systems planning, and patient care management.
• Self-directed with the ability to adapt in a changing environment.
• Basic knowledge of computer systems with skills applicable to the utilization review process.

Pay

Salary Range: $77,075.00 - $119,466.00

Schedule

Day shift