RN Case Manager/UT Review

Essential Functions

• Work with the UR, SW, and Department Director to identify potential candidates for the skilled care program.
• Ensure that the patient meets qualifications for skilled care.
• Facilitate issuance of the hospital issued notice of non-coverage (HINN).
• Discuss with the patient/family change in level of care from acute to skilled care status.
• Ensure that physician orders and certification for skilled care services are obtained in a timely manner.
• Maintain patient census log for skilled care program, which includes records of all patients screened and admitted to the skilled care program.
• Facilitate assessment of all patients admitted to the skilled care program.
• Complete the Resident Assessment Instrument Minimum Data Set (RAI-MDS; also called MDS) according to Medicare schedule for Skilled Care.
• 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 log of RUG categories and services that are excluded from consolidated billing.
• Submit information to the business office for timely billing of the skilled care claim.
• Involvement in 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 about state-required assessments, including requirements on completion of the MDS, according to defined coding to ensure proper reimbursement for care.
• Avoid involvement in the 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 that apply to patient care, reimbursement, and surveys.
• Utilize and attend skilled care continuing education when possible.
• Collaborate with and assist the Social Work department in the Discharge Planning Process.
• Ensure the discharge plan is initiated and is revised according to patient progress; verify the patient/family is informed of discharge plans; verify postdischarge care needs are identified and addressed.
• Serve as a resource for the patient, family and physician. Meet with patient, family and physicians as needed to address issues that arise.
• Collaborate with and assist Utilization Review Nurses.

Knowledge, Skills, and Abilities

• Will be orientated to and maintain competence in working with adult and geriatric patients.
• Competence at the beginning of employment will be measured through observation during orientation, math and medication administration testing, and review of documentation.
• Ongoing competence will be measured through observation of clinical practice, observation for performance evaluation, competency inservice and testing, and math and medication administration testing.