Care Manager I

Outcomes Case Manager

The Outcomes Case Manager is responsible for coordinating patient care, managing transitions across the continuum of care, and improving clinical, quality, and financial outcomes. This role collaborates with physicians, nurses, interdisciplinary teams, patients, families, and community resources to ensure appropriate care progression, timely discharge planning, reduced readmissions, and achievement of organizational quality metrics.

Essential Duties and Responsibilities:

• Manages an assigned caseload of patients from preadmission to discharge.
• Assumes responsibility for admission appropriateness (medical necessity), (outpatient, observation, inpatient admission), continued stay, and medical record monitoring
• Coordinates communication with third party payers, external review agencies and the Utilization Committee.
• Identify managed care issues and address promptly as related to denials management
• Coordinates and collaborates with physicians, provider, multidisciplinary team and other health care professionals concerning patient's goals, plan of care and progress.
• Revises and adjusts on a daily basis the plan of care to accommodate the needs of the individual patient based on continuing assessment of patient condition.
• Leads discharge planning multidisciplinary team meetings, ensures documentation of meetings
• Advocates for the patient/family and is knowledgeable of and act in accordance with legal principles of consent, healthcare proxies (power of attorney for healthcare) and advance medical directives.
• Stays abreast of developments in the case management field and seeks ongoing education to enhance practice skills. Care Management is willing to seek certification in case management field if made available through ARH.
• Stays abreast of regulatory agency guidelines as pertains to area of practice
• Initiates and monitors clinical care guidelines and analyzes positive and negative variances
• Ensures continuity of care through formulation of discharge plan on admission and follow though until patient is discharged.
• Ensures appropriate use of resources.
• Monitors patient care for appropriate use of resources.
• Monitors length of stay on a concurrent, weekly, and monthly basis. Ensures that length of stay is appropriate based on medical necessity. Works with medical staff, hospital staff, and others to overcome barriers to discharge.
• Monitors in-house denials for extended lengths of stay.
• Participates in the denials management process to help ensure establishment of and adherence to processes that will minimize denials by third-party payers.
• Participates as a member of the Utilization Committee
• Assists in the collection of data to trend and analyze outcomes for identification of improvement opportunities.
• Participates in data collection, specific to outcomes data.
• Assesses the appropriateness of the level of care; diagnostic testing and clinical procedures; quality and clinical risk issues; and documentation of medical record completeness.
• Performs other related duties as assigned.

Qualifications:

• Associate's Degree Registered Nurse (licensed in state of employment) Preferred
• Bachelor's Degree Nursing; Must be obtained within 5 years Preferred
• 4-6 years 5 Years of nursing experience may be considered with demonstration of skills required for the position. Preferred
• Advanced knowledge of problem solving and decision making skills.
• Strong multi-tasking abilities with the ability to handle competing deadlines; flexible and adaptable.
• Ability to deal tactfully with customers and community.
• Advanced communication skills used to lead a team.
• Advanced execution and delivery (planning, delivering, and supporting) skills.
• Ability to consider the relative costs and benefits of potential actions to choose the most appropriate one.
• Ability to function in clinical setting with diverse cultural dynamics of clinical staff and patients.
• Mastery knowledge of phases of care transitions and resources available for patients.
• Mastery of digital literacy skills.
• Ability to handle sensitive information ethically and responsibly.
• RN Preferred
• LPN Required

Harlan Appalachian Regional Healthcare