RN Case Manager / per-diem

Job Description Summary 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. Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically-based case management, discharge planning and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care. Works collaboratively with interdisciplinary staff internal and external to the Organization. Participates in quality improvement and evaluation processes related to the management of patient care. Commits to working a minimum of 32 hours, with at least 16 hours (in 2 shifts) worked during a night and/or weekend per 4‑week schedule. Also works 1 major summer or winter holiday. ESSENTIAL FUNCTIONS 1. Review medical records for observation and inpatient admissions and continued stays 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 them of the decision to issue notice of non‑coverage. Explains UR process and insurance coverage requirements. Obtains physician written concurrence when necessary; e.g., Medicare patients. Informs the patient and/or next of kin when insurance coverage must be terminated for the current admission. Issues the termination letter for the Medicare patient. Reinstates insurance coverage when patient condition becomes acute and meets criteria again. Issues reinstatement letter. Continuously reviews 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. 2. Assist physicians, nursing and staff with 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 questionable status to internal physician advisor or EHR according to departmental process. Assumes 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. RN Case Manager must take telephone orders from physicians changing patient status from observation to inpatient admission. Makes a call or page if the RN Case Manager believes this should be an inpatient admission and not wait until the 24‑hour benchmark. Actively monitors patients on observation status and seeks to clarify status as close to the 24‑hour benchmark as possible. Sends a concern in a timely fashion to facilitate correct patient status and timely notification. 3. Participate 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. 4. Assess patient acute level of care needs and coordinate interventions for safe and timely discharge to appropriate sub‑acute settings 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. 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. Coordinates the necessary resources to accomplish goals developed in plan. Proactively facilitates efficient flow of care and anticipates discharge process. Gathers information from multidisciplinary team and monitors appropriate discharge plan. 5. Maintain interdisciplinary communication and documentation Uses and updates the interdisciplinary patient White Board for communication enhancement; includes RN Case Manager name, time/date/plan for discharge. Issues the Medicare Important Message (IM). Uses proper Medical Necessity form for post‑discharge transportation. Uses technical tools, i.e., eDischarge, EHR, Interqual, MCCM. Facilitates establishment of a patient’s Health Care Proxy. Identifies patient Care Plan Partner. Fosters patient and family awareness of Patient Portal. 6. Ensure patient receives all information related to choice of follow‑up care facilities Ensures that, at minimum, three referrals are processed for continuum of care providers. Documents choices provided, with special consideration of ACO relationships and preferences; and selections made by patient and/or family in medical record. Expedites and processes 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. Documents response by providers. Delivers the Medicare Important Message (IM) per department protocol. Has patient, family/healthcare Proxy sign discharge plan. 7. Interact, communicate, and intervene with multidisciplinary team to maximize resource utilization 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 proactive 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 comments on the patient’s clinical state. Coordinates and participates 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. 8. Establish and maintain effective communication with all referral sources, insurers, vendors and patient supplier systems Responsible for ongoing communication and coordination with referral sources, insurers, vendors and patient supplier systems. 9. Maintain professional commitment to institutional and departmental goals Demonstrates flexibility to department needs in relation to floor and work schedule, and any other internal and external demands on the department. Continually shows commitment to the Department by extending self when need arises. 10. Keep an updated knowledge base of provider benefits and community resources Maintains a working knowledge of the requirements of the payers most frequently seen with the patient population. Maintains a working knowledge of the resources available in the community for patients/families. Maintains current nursing licensure CEU credits, case management certification CEUs. Maintains Interqual certification. 11. Ensure departmental operational excellence Manages all activities so that quality services are provided in an efficient and effective manner. Services provided meet all applicable regulatory requirements. Participates in departmental and organizational quality improvement initiatives involving Lean principles and TIM WOODS. Maintains departmental productivity measurements. Has awareness of departmental productivity measurements including LOS and utilization. Follows department policies, procedures, and standards of care that support operational excellence and productivity measurements. 12. Attain all agreed‑to goals and objectives within specified time frames Consistently meets goal and objective deadlines as part of the organization’s overall mission. 13. Embrace technological solutions to work processes and practices Utilizes eDischarge, EHR, Interqual, MCCM, Epic, Workday. Job Requirements Minimum Education: Registered Nurse. Preferred: Bachelors prepared strongly preferred. Minimum Work Experience: 3‑5 years acute care hospital experience is preferred. Critical Care or Emergency Department experience is highly desirable. Required Licenses/Registrations: RN – Registered Nurse. Required Certifications: ACM‑Accredited Case Manager or CCM‑Certified Case Manager within two years of hire. Required Additional Knowledge and Abilities: Demonstrated skills in negotiation, communication (verbal and written), conflict resolution, interdisciplinary collaboration, management, creative problem solving, critical thinking, time management and ability to multitask in high‑stress environment. Knowledge of healthcare financing, community and organizational resources, patient care processes, and data analysis. Knowledge of utilization management as it relates to third‑party payers. Knowledge of post‑acute care community resources. Experience with Managed Care preferred. Excellent verbal and written communication skills required. Demonstrates flexibility via an ability to adapt to changing priorities and regulations. Basic computer skills required. #J-18808-Ljbffr