Case Manager

Complex Case Manager

Practices with minimum supervision from another licensed professional and is able to perform the following components of care management according to the Case Management Society of America Standards: assessment, facilitating planning, advocating, monitoring, evaluation, and outcomes. In collaboration with all healthcare professionals involved this position is also able to demonstrate the above components within the following core activities: coordination and service delivery, physical and psychological factors, benefit systems cost analysis, care management concepts, and community resources.

The Complex Case Manager facilitates communication and coordinates between all members of the healthcare team involving the patient and family in the decision-making process in order to minimize the fragmentation of the healthcare delivery system. The Complex Case Manager is a leader in effecting change to improve the quality of patient care through being an advocate ensuring the patient is receiving the most appropriate level of care, the patient is progressing in their care, moving toward transitioning to the next lower level of care, as well as demonstrating knowledge on reducing the cost of services on a care-by-care basis as appropriate.

The Complex Case Manager understands financial implications of care in today’s healthcare environment such as (but not limited to): requirements for prior approval by payer, cares which would benefit from alternative care, analysis of necessary medical services for cost containment, healthcare plans for appropriateness, home health/hospice resources, healthcare delivery systems, DRG system care mix index, managed care, and capitation. Responsibilities also include facilitating the admission process for non-elective emergency inpatient admissions and outpatient observation stays, monitoring observation stays at the end of 23 hours for possible inpatient admission or discharge planning. The Complex Case Manager will work closely with the UM team ensuring that all patients are screened against Interqual/Milliman or other appropriate criteria and assist the physician in identifying alternative methods of care when criteria are not met. Works closely with the Physician Advisor on cares that do not meet admission criteria or continued stay criteria. The Complex Case Manager will transition the patient once all complex CM activities have been completed for discharge planning services such as Home Health and DME referrals to the PARCC team (usually within 24-48 hours prior to discharge) for completion of discharge planning and safe transitions to the next level of care. The complex care manager and care coordinator will work in collaboration as a team to ensure timely provision of services. The care manager will be responsible for identifying long stay patients collaborating with all members of the disciplinary team to close loops and offer alternatives as appropriate. The complex care manager will assist in program development and implementation for specific programs and plans of patient care such as clinical pathway population specific and disease management initiatives. The nurse care manager will manage/coordinate the care of an average care load of 25 patients per day.

Job Qualifications:

• Education: Graduate of an accredited School of Nursing.
• Licensure: Current RN required BSN preferred Nursing license in the State of Georgia. BLS CPR required.
• Certification: Certification in Care Management is desired.
• Experience: Three - Five years of nursing experience as a RN with two years of recent clinical experience required. Utilization Review Case Management experience of at least one year is preferred. Experience with computer skills required.
• Skills and Personal: Skilled in the art of human relations problem solving and conflict resolution/negotiation. Ability to articulate knowledge to others. Demonstrates good role model qualities ability to effectively interpret implement and support approved hospital policies regulations philosophy and objectives. Is self-directed in maintaining and improving own knowledge in clinical skills as well as cognitive aspects of patient care nursing theory current research and care management. Capable of effecting positive change across all departments to improve the quality of patient care and reduce the cost of services. Ability to do 1:1 and group teaching.

Physical, Mental, Environmental, and Working Conditions:

Works in a typical acute health care setting with adult, geriatric, newborn, special care nurseries, pediatric patients and families experiencing a wide range of medical and/or surgical problems. Requires flexible work schedule to include weekends, holidays, and evening hours as needed to meet patient needs. Requires ability to lift and turn patients. Manual and finger dexterity and eye-hand coordination is necessary. Requires standing and walking for extensive periods of time. Requires corrected vision and hearing to normal range. Requires working under stressful conditions. Requires exposure to communicable diseases or body fluids. Requires working with computers. Requires prolonged periods of time spent on the telephone.

Full-Time Benefits:

• 403(b) Matching (Retirement)
• Dental insurance
• Employee assistance program (EAP)
• Employee wellness program
• Employer paid Life and AD&D insurance
• Employer paid Short and Long-Term Disability
• Flexible Spending Accounts
• ICHRA for health insurance
• Paid Annual Leave (Time off)
• Vision insurance