Case Manager - AOMC

CASE MANAGER

**This is an onsite position.

MAIN FUNCTION:

The Case Manager coordinates, negotiates, procures services resources for and manages the care of complex patients to facilitate achievement of quality and cost, patient outcomes. The Case Manager works collaboratively with interdisciplinary staff internal and external to the organization. The Case Manager participates in quality improvement and evaluation processes related to the management of patient care. The Case Manager will review all patients for utilization management and appropriate discharge planning. The Case Manager's average caseload will be: 15-25. The Case Manager will work cooperatively within the care team.

DUTIES AND RESPONSIBILITIES:

• Determines medical necessity and appropriateness of admission and stay in accordance with InterQual.
• Prepares Medicare/Non Medicare hospital notices of no coverage (HINN) when patient's level of care is no longer covered according to the guidelines.
• Identifies the appropriate patients for Case Management services.
• Maintains a working knowledge of the requirements of 3rd party payers most frequently involved with their caseload population.
• Communicates, collaborates, and coordinate with physicians, other members of the team, the patient's payers and administrators to assess the needs and provide a plan of care for their caseload population.
• In conjunction with the patient/family, other members of the health care team, the payer, and available resources, formulates a plan to address assessed needs and issues, implements the plan, evaluates the effectiveness of the plan in meeting established care goals and revises the plan as needed to reflect the changing needs, issues and goal.
• Explores and facilitates strategies to reduce length of stay and resource consumption within case managed populations, implements these strategies and documents the results.
• Manages each patient's transitions through the Health Care system and maintains appropriate documentation of the patient care and progress.
• Identifies the need, arranges for and conducts health care team meetings when necessary to facilitate the coordination of services and resources in complex situations.
• Seeks and provides peer consultation about cases presenting problemsand/or experiencing significant deviation from the plan of care.
• Consistently attends daily care rounds and participates in them.
• The Case Manager tracks and trends LOS, resource utilization , outliers, readmissions, denials, delay days and satisfaction of the case managed population.
• Maintains a close working relationship with physicians managing the care of their caseload population.
• Coordinates patient discharge and transfers based on the patients need and available resources.
• Coordinates services, i.e. home help, DME etc, based on patient need and resources available.
• This job description lists typical duties for the classification and is not to be considered inclusive of all duties that may be assigned.

MEETINGS:

Case management staff meeting. staff development meetings. Programs of care.

EDUCATION:

Graduate of an approved registered nursing program with a current license as a registered nurse. BSN or Case Management Certification preferred.

EXPERIENCE:

Three to five years clinical nursing in acute care hospital setting preferred. . Case management experience preferred but not required.

CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:

Basic Life Support (BLS) required within 90 days of hire date.

PHYSICAL DEMANDS:

Light physical effort. Routine office job.

Category I. Tasks that involve exposure to blood, body fluids, or tissues.

A.D.A. Essential Functions