RN Care Manager - Full Time - Day - Corp Care management

About the Role

Promotes and facilitates effective management of hospital resources from admission to discharge, collaborating with the assigned clinical team to identify patients most likely to benefit from care coordination services. This includes assessing patients' risk factors and the need for care coordination, clinical utilization management, and transition to the next appropriate level of care.

Responsibilities

• Initially and concurrently assess all patients within assigned population, including but not limited to:
  • Accurate medical necessity screening and submission for Physician Advisor review
  • Care coordination assessing admitting diagnosis, medical history, current treatments, age, payment source, resources, support systems, anticipated needs, expected length of stay, appropriate level of service, special/personal needs, and other relevant information
  • Assignment of initial DRG to determine GMLOS, while concurrently monitoring and managing LOS and transition planning using InterQual guidelines
• Lead and facilitate multi-disciplinary patient care conferences
• Manage concurrent disputes
• Make appropriate referrals to other departments
• Identify and refer complex patients to Social Work Services
• Communicate with patients and families about the plan of care
• Lead and facilitate Complex Case Review
• Identify and document potentially avoidable days
• Identify and report over- and underutilization
• Ensure compliance with all regulatory standards including Federal, State, Local, and Joint Commission review requirements for Managed Contracts, Medicare, Medicaid, and related to admission and continued stay approval
• Adhere to Utilization Management Plan
• Integrate national standards for care management scope of services, including:
  • Utilization Management supporting medical necessity and denial prevention
  • Transition Management promoting appropriate length of stay, readmission prevention, and patient satisfaction
  • Care Coordination demonstrating throughput efficiency while ensuring care is in the right sequence and at the appropriate level
  • Education provided to physicians, patients, families, and caregivers
• Communicate appropriately and timely with the interdisciplinary team and third-party payers
• Prioritize activities in assigned areas to focus on high risk, high cost, and problem-prone areas
• Develop collaborative relationships with patient business, nursing, physicians, and patient/family to facilitate efficient movement through the continuum of care
• Monitor and evaluate data, fiscal outcomes, and other relevant information to develop and implement strategies for improvement
• Forward identified quality and/or risk issues appropriately
• Maintain positive relationships with outside/onsite reviewers and other payer representatives
• Identify cultural, socio-economic, religious, and other factors that may impact treatment
• Involve patient’s family in the development of the treatment plan as appropriate, explaining procedures, therapies, systems treatment plans, and discharge plans in age/developmental/educational specific terms
• Review patient’s discharge plan at multidisciplinary meetings and/or staffing to facilitate communication with other healthcare team members
• Prioritize workload to manage multiple priorities while using problem-solving skills to meet goals
• Enhance professional growth by participating in educational programs, current literature, and/or workshops
• Maintain excellent interpersonal skills and ability to work in a team environment
• Respect the rights and privacy of others and hold staff member information in strict confidence
• Maintain reasonably regular, punctual attendance consistent with policies and federal, state, and local standards
• Maintain compliance with all policies and procedures
• Maintain records and documentation of work performed in an organized and easily retrievable fashion while maintaining confidentiality
• Review current literature regularly, maintain reference materials, and stay abreast of relevant reimbursement information
• Actively serve on committees and task forces to promote quality, cost-effective care for patient population
• Perform other duties as assigned or required

Requirements

• Graduate of an approved school of nursing
• Three (3) years of experience in chronic disease management, care management, care coordination, utilization management, or acute clinical care
• Current Florida RN license
• Handle with Care (HWC) Certification required for the Behavioral Health Unit within 90 days of hire (training provided onsite)

Skills

• Demonstrated organizational skills
• Excellent verbal and written communication skills
• Ability to lead and coordinate activities of a diverse group of people in a fast-paced environment
• Critical thinking and problem-solving skills
• Computer literacy