Per Diem Case Manager

About the role

Under the general supervision of the Case Management Manager acts as a patient advocate/Case Manager to SSH&EC clients. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost efficient patient outcomes. Looks for opportunities to reduce cost while assuring the highest quality of care is maintained.

Responsibilities

• Reviews the medical record of all observation and inpatient admissions and continued stays to ensure appropriate utilization and delivery of care.
  • Using Interqual Criteria, physician certification, and payor specific criteria, assists the physician in determining the medical necessity for observation, admission and continued stays.
  • Identifies cases daily that fail to meet criteria and refers these cases to appropriate manager or physician advisor for secondary review.
  • Contacts attending physicians daily on cases that lack adequate documentation warranting acute hospitalization and clarifies for them the necessary clinical documentation required to help support medical necessity.
  • Contacts the attending physician to notify him/her of decision to issue notice of non-coverage. Explains UR process and insurance coverage requirements. Obtains physician written concurrence when necessary; e.g., Medicare patients.
  • Issues the termination letter for the Medicare patient. Issues reinstatement letter.
  • Continues review of all patients using criteria and determines need for continued hospitalization based upon third party payor/insurance guidelines.
  • Provides clinical data/information to contracted third-party payers while patient is hospitalized to ensure continued reimbursement and to avoid reimbursement delays within 24 hours of request.
  • Continues review of all patients using criteria and determines need for continued hospitalization based upon third party payer/guidelines.
• Aids in the accurate determination of a patient’s observation status.
  • Identifies and reviews observation patients to determine the correct patient level of care daily prior to 12 PM.
  • Consults with physicians, nursing, admitting, and outside insurance case managers to determine the appropriate status of patient. Refers the questionable status to internal physician advisor or EHR according to the Departmental Process.
  • Assumes the role of review coordinator for observation services; reviews medical record for appropriateness of status and level of care, and facilitates the level of care, utilizing InterQual for Observation.
  • Works with physicians, nursing and staff, patients and families to arrange prompt and safe discharge.
• Participates in case finding and pre-admission evaluation screening to assure reimbursement.
  • Identifies potential transition planning problems in a timely manner to set up services required.
  • Works with attending physician to move patient through the SSH&EC system and set up appropriate services or referrals; e.g., SNF/VNA/Home Pharmacy.
  • Identifies need for new resources if gaps exist in service continuum, and initiates creative care delivery options.
• Assesses patient acute level of care needs and works to implement and coordinate interventions aimed at facilitating a safe and timely discharge plan to the appropriate sub-acute settings in collaboration with the Case Manager Specialist.
  • With the Case Manager, work to identify, and prioritize workflow through identification of patient specific, department needs and or unit based needs.
  • Executes and implements a safe and effective discharge plan based on the case management assessment in accordance with the Conditions of Participation.
  • Makes and documents appropriate changes to discharge plan when necessary.
  • Proactively uncovers barriers to early/timely discharge and overcomes them.
  • Facilitates and coordinates patient care rounds.
  • Conducts necessary conferences and team meetings regarding specific patient needs.
  • Implements interventions that lead to patient accomplishing goals established in Plan.
  • Captures and documents appropriate resources to accomplish goals developed in Plan.
  • Proactively affects system to facilitate efficient flow of care, anticipates discharge process.
  • Gathers information from multidisciplinary team and monitors appropriate discharge plan.
• Ensures that patient has received all information related to choice of follow-up care facilities according to patient and family preference and any ACO preferred contracted providers.
  • Ensure that, at minimum, 3 referrals are processed for continuum of care providers.
  • Document choices provided, with special consideration of ACO relationships and preferences; and selections made by patient and/or family in medical record.
  • Expedites and process referrals, in a timely manner to department standards, including requesting and tracking screenings and acceptances of patients by care providers, expediting responses from provider facility personnel as necessary.
  • Document response by providers.
  • Delivers the Medicare Important Message (IM) per department protocol.
  • Have patient, family/healthcare Proxy sign discharge plan.
• Interacts, communicates, and intervenes with multi-disciplinary healthcare team in a purposeful, goal-directed fashion. Works pro-actively and utilizes critical thinking skills to maximize the effectiveness of resource utilization. Anticipates, initiates, and facilitates problem resolution around issues of resource use and continued hospitalization, discharge planning.
  • Establishes a means of communicating and collaborating with physicians, other team members, the patient’s payers, and administrators.
  • Explores strategies to reduce length of stay and resource consumption within the care managed patient populations, implements them and documents the results.
  • Communicates to appropriate members of healthcare team patients at risk of losing insurance coverage via termination of benefits, facilitates discharge plan.
  • Maintains a pro-active role to ensure appropriate documentation concurrently to minimize inefficient resource utilization and prevent loss of reimbursement.
  • Reviews physician documentation and follows procedures to seek clarification where indicated of that documentation relative to diagnosis and comment on the patient’s clinical state.
  • Coordinate and participate in daily multidisciplinary patient care rounds.
  • Uses the SBAR method to communicate with MD, and peers.
  • Acts as a clinical resource to support the Case Manager Specialist in resource utilization and discharge planning the more clinically complex or long length of stay patient.
• Establishes and maintains effective communication with all referral sources, insurers, vendors and patient supplier systems.

Requirements

• Minimum Education - Preferred Registered Nurse, Bachelors prepared strongly preferred
• Minimum Work Experience 3-5 years acute care hospital experience preferred
• Critical Care or Emergency Department experience highly desirable

Qualifications

• RN - Registered Nurse
• ACM-Accredited Case Manager or CCM-Certified Case Manager within two years of hire
• R