Lead Case Manager

Job Summary

The Lead Case Manager is a hospital-based professional providing clinically based care management to support effective and efficient patient and family-centered care in the acute care hospital setting. Responsibilities include collaborating with medical staff, patients, families, and the health care team to assess, facilitate, plan, and advocate for health needs on an individual basis, ensuring quality, cost-effective outcomes.

Essential Functions

• Applies up-to-date information related to reimbursement procedures, managed care contracts, and patient status in facilitating/collaborating in the plan of care.
• Captures the provider aspect of federal/state organization functions as detailed in the Conditions of Participation and other appropriate regulations.
• Serves as a resource on the unit, coordinating interdisciplinary team huddles/communication, identifying and communicating the patient's health care needs based on best practice standards to ensure care and communication needs are met in relation to both internal and external providers/services, ancillary department services, core measures, compliance with internal policies/regulatory guidelines, and True North metrics.
• Supports compliance with Utilization Review and regulatory guidelines. Identifies trends related to compliance of regulations and collaborates with appropriate hospital personnel and external agencies to ensure appropriate process changes are implemented.
• Supports the Medical Staff Quality Review process by identifying issues related to quality indicators set forth by the Medical Staff.
• Creates and updates the Plan of Care (POC) to include patient/family-centered goals with interventions that reflect the changing needs of the patient/family unit and are consistent with their current needs and desires.
• Maintains a working knowledge and relationship with community resources and payer benefits that link the individual with the most appropriate resources.
• Facilitates planning for patient/family needs to ensure a smooth transition for the patient across the continuum of care.
• Evaluates current treatment plan to identify barriers, determine realistic goals and objectives, and seek potential alternatives in conjunction with the medical staff.
• Coordinates team efforts with support services departments to ensure appropriate care and smooth discharge transition.
• Assists by maintaining expertise on benefits, reimbursement, and contract/regulation changes per payer guidelines, Medicare, and Medicaid to facilitate appropriate reimbursement, education, and guidance to assist the healthcare team and patient/family in decision-making.

Required Additional Requirements

• Education: Completion of nursing education program that is approved by a board of nursing or Bachelors/Masters Degree in Social Services.
• Certification: Registered Nurse (RN) - South Dakota Board of Nursing or Certified Social Work (CSW) - South Dakota Department of Social Services.
• Experience: 2+ years of Acute Experience; 2+ years of Registered Nurse Experience or for Social Services - 3+ years of Healthcare related Experience.
• Certification: Commission for Case Management Certification (CCMC) - Accredited University or accredited training professionals.