RN Case Manager/UR

About the role

This position is responsible for ensuring appropriate patients are admitted to the skilled care program and maintaining compliance with Medicare and state regulations for skilled care services.

Responsibilities

• Work with Utilization Review (UR), Social Work (SW), and Department Director to identify potential candidates for the skilled care program.
• Ensure patients meet qualifications for skilled care.
• Facilitate issuance of the hospital-issued notice of non-coverage (HINN).
• Discuss with patients/families the change in level of care from acute to skilled care status.
• Ensure physician orders and certification for skilled care services are obtained in a timely manner.
• Maintain patient census log for the skilled care program, including records of all patients screened and admitted.
• Facilitate assessment of all patients admitted to the skilled care program.
• Complete the Resident Assessment Instrument Minimum Data Set (RAI-MDS) according to Medicare schedule for Skilled Care.
• Supervise and coordinate the Activities Program for Skilled Care/Swing Bed patients.
• Perform the Essential Functions of the Nursing Activity Clerk.
• Meet CMS requirements for initiating, updating, and maintaining the care plan.
• Maintain knowledge of state-required assessments, including MDS completion requirements and coding for proper reimbursement.
• Assist the Discharge Planning Team in reviewing patient goals; revise and complete goals as appropriate.
• Facilitate interdisciplinary care for patients in the Skilled Care Program.
• Attend and participate in Discharge Planning Team meetings.
• Document patient information in the Electronic Medical Record.
• Participate in quality assurance, assessment, and improvement activities.
• Maintain current knowledge of the Skilled Care Program and regulations related to patient care, reimbursement, and surveys.
• Utilize and attend skilled care continuing education when possible.
• Serve as a liaison between patients, families, physicians, management, and staff.
• Communicate regularly with director, staff, and physicians.
• Communicate the Resource Utilization Group (RUG) category and other clinical information needed to process claims.
• Maintain a log of RUG categories and services excluded from consolidated billing.
• Submit information to the business office for timely billing of the skilled care claim.
• Involve patients and families in the plan of care by discussing the plan with them.
• Invite patients and/or families to care planning meetings as appropriate.
• Review all care plans and goals with patients or families who did not attend care plan meetings.
• Ensure patient information is shared with appropriate disciplines.
• Collaborate with and assist the Social Work department in the Discharge Planning Process.
• Ensure the discharge plan is initiated and revised according to patient progress.
• Verify the patient/family is informed of discharge plans and that post-discharge care needs are identified and addressed.
• Serve as a resource for patients, families, and physicians.
• Meet with patients, families, and physicians as needed to address issues that arise.
• Collaborate with and assist Utilization Review Nurses.
• Perform other duties as assigned.
• Perform the Essential Functions of Ward Clerk.
• Perform the Essential Functions of Staff Registered Nurse.

Knowledge, Skills, and Abilities

• Competence in working with adult and geriatric patients.
• Competence measured through observation during orientation, math and medication administration testing, and review of documentation.
• Ongoing competence measured through observation of clinical practice, performance evaluations, competency inservices and testing, and math and medication administration testing.