Case Management Nurse - Full Time

Case Management Nurse - Full Time

Coordinates services through a multi-disciplinary process that provides a clinical and psychosocial approach through the continuum of care. Assists in development, planning, coordination and administration of the activities of clinical review, discharge planning, resource utilization, and utilization review. Assures quality, cost-effective care for the identified patient population. Essential to this role are the core values of patient advocacy, holistic assessment, care planning, and empowerment of patients and families to be involved in their care.

Essential Functions

• Build collaborative relationships with staff, peers, and physicians.
• Communicate with clarity, integrity, and purpose so that goals and outcomes are optimized
• Maintain professional and technical knowledge by attending educational opportunities.
• Interact with and contribute to the professional development of peers by sharing skills, knowledge, and experience and respecting the contributions of others.
• Follow all safety precautions, including universal precautions and infection control procedures.
• Promote effective and efficient utilization of clinical resources.
• Assess the medical necessity of all admissions, validating the need for hospitalization under the correct patient status.
• Competently assess the needs of the patient and their family at the time of admission and throughout the hospital stay.
• In collaboration with the multi-disciplinary team, develop and implement an appropriate discharge plan for assigned patients.
• Assist in monitoring and evaluating patient/family progress according to goals set within the discharge plan.
• Act as an effective liaison between the facility and payers to optimize patient/family re-integration into the community.
• Coordinate the integration of various social services into all aspects of patient care.
• Meet documentation requirements according to facility/state/federal guidelines.
• Documentation should reflect psychosocial and medical background to include, high-risk screenings related to case management and proposed interventions/outcomes.
• Performs proactive discharge planning, beginning on the day of admission, which includes patient/family education and the development/implementation of a safe and quality-driven post-discharge plan.
• Demonstrate creative problem-solving skills, utilizing innovation and a team approach.
• Demonstrates clinical judgment to determine appropriate interventions to address patient needs and barriers to patient progression through the continuum.
• Demonstrates understanding of utilization management for all patients, regardless of payer status.
• Maintain thorough understanding of CMS regulations, as well as other payer processes supporting authorization and identification of correct patient types (Inpatient, Observation, and Outpatient).
• Collaborates with Social Workers on complex cases to ensure a successful discharge plan.
• Consults with providers for care as needed and make referrals for identified continued care needs.
• Support chart audit functions including RAC and third-party requests.
• Assist in identifying department interventions and priority expectations to improve case management metrics (LOS reduction, Readmission reduction, discharge times, etc.)
• Practice autonomously, consistent with practice standards, policy, and procedures.
• Escalate cases as needed to Physician Advisor for needed intervention.
• Provide excellent customer service and hand-off communication.
• Participate in department/organizational performance improvement activities.
• Demonstrate commitment to the mission, vision, and values of the organization.

Required Skills

Minimum Education: Graduate from an accredited nursing program.

Required Degree: Associate degree in Nursing required. Bachelor's degree in Nursing preferred. ACM or CCM Certification preferred.

Work Experience: Minimum three years acute care experience, one year in Case Management. Strong clinical and communication skills. Experience with InterQual criteria preferred.

Licensure: Licensed to practice in the State of Kentucky. Current BLS Certification required.

Required Skills: A working knowledge and understanding of Medicare/Medicare Advantage, Medicaid, Commercial, and other third-party reimbursement processes. Proven organization and problem-solving skills. Excellent customer service skills. Ability to demonstrate a strong commitment to customer service and teamwork.