Case Manager RN

Case Manager RN

Are you looking to make a difference by improving the health of our patients? Here you will find an innovative culture that is patient-focused and dedicated to making a difference. We are committed to helping the population we serve, and our communities, achieve optimum health and enjoy the best quality of life possible.

The Case Manager RN supports the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The Case Manager is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include:

• Facilitation of precertification and or payor authorization processes
• Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement
• Application of process improvement methodologies in evaluating outcomes of care
• Support and coaching of clinical documentation efforts
• Coordinating communication with physicians

Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the patient served.

• Coordinates/facilitates patient care progression throughout the continuum.
• Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management.
• Addresses/resolves system problems impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge.
• Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge
• Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
• Collaborates with physician and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis:
• Completion and reporting diagnostic testing
• Completion of treatment plan and discharge plan
• Modification of plan of care, as necessary, to meet the ongoing needs of the patient
• Communication to third party payors and other relevant information to the care team
• Assignment of appropriate levels of care
• Completion of all required documentation in Milliman and EPIC
• Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in appropriate setting.
• Completes utilization management and quality screening for assigned patients.
• Applies Milliman Criteria to monitor appropriateness of admissions and continued stays, and documents findings based on Department standards.
• Identifies at-risk population using approved screening tool and follows established reporting procedure
• Monitors LOS and ancillary resources on an ongoing basis. Takes action to achieve continuous improvement in both areas.
• Refers cases and issues to Case Review, Utilization Committee, Medical Director, and Director of Quality in compliance with department procedure and follows up as indicated.
• Communicates with Finance Department on issues of insurance, denials, authorizations and self-pay issues as needed
• Interfaces with IPRO and other review agencies regarding denials, retrospective reviews.
• Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
• Manages all aspects of discharge planning for assigned patients.
• Meets directly with patient/families to assess needs and develop an individualized continuing care plan in collaboration with physician.
• Collaborates/communicates with Multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, and teaching and ongoing evaluation.
• Ensures/maintains plan consensus from patient/family, physician and payor.
• Refers appropriate cases for social work intervention based on department criteria.
• Collaborates/communicates with external case managers, admissions personnel.
• Initiates and facilitates referrals for home health care, durable medical equipment and supplies.
• Maintains a current knowledge of resources available within the community and maintains a supply of resource materials to be distributed to patients when needed.
• Documents relevant discharge planning information in the medical record according to department standards.
• Facilitates transfer to other facilities as appropriate.
• Actively participates in clinical performance improvement activities.
• Assists in the collecting and reporting of resources and financial indicators including LOS, excess days, resource utilization, denials and appeals, swing bed statistics.
• Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data.
• Collects, analyzes and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes.
• Collects delay and other data for specific performance and/or outcome indicators as determined by Director of Quality.
• Ensures safe care to patients adhering to policies, procedures, and standards.
• Manages Swing Bed Patients
• Monitors appropriateness of continued stay and documents findings.
• Collaborates/communicates with Multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation and attending family meetings
• Administers written notice of acceptance to swing bed program.
• Evaluates patients for acceptance into Little Falls Hospital swing bed program; establishes medical need for swing bed services.
• Receives and reviews all clinical information from other acute facilities and confirms financial benefit for swing bed placement from business office.
• Maintains a level of competence and expertise by attending seminars, workshops and meetings of regional peer organizations regarding quality and utilization/resource management.
• Maintains an appropriate, professional personal appearance, including but not limited to wearing required safety apparel when warranted.
• Assists to ensure departmental operations are in compliance with TJC, state, federal, malpractice carrier, and all other applicable standards, laws or regulations.
• Assists in the recruitment process for applicable Quality Resources employees; trains and orients new employees.
• Uses supplies and institutional resources in a financially responsible manner.
• Maintains an orderly, clean, and safe work environment.
• Attends all Committee meetings as requested and facilitates meetings as assigned.
• Participates in Relationship Based Care Unit Practice meetings and Performance Improvement Team meetings.
• Performs similar or related duties as requested or directed.

Education:

• 4 Year/Bachelor's Degree in Nursing or Social Work, preferred (of willingness to complete a Bachelor's Degree within a specified time period
• 2 Year/Associates Degree in Human Services related field, required

Experience:

• Minimum 5 years clinical experience in a healthcare setting, preferred

Licensure/Certifications:

• Current NYS licensure as a Registered Professional Nurse, if applying as a nurse, required
• Case Management certification, preferred
• Case Management certification within 5 years from date of hire, required

Skills:

• Accountability
• Customer Service
• Advocacy
• Attention to Detail
• Computer Skills
• Conflict Resolution
• Interacting with People

Physical Requirements:

• Sedentary Work - Exerting up to 10 lbs of force occasionally, and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Sedentary work involves sitting most of the time. Jobs are sedentary if walking or standing are