Case Manager

Position Summary The position provides comprehensive care coordination for patients and assesses their plan of care. The Case Manager is responsible for length of stay management and discharge planning, developing, implementing, monitoring, and documenting the utilization of resources and progress of the patient through their care. The Case Manager advocates and facilitates options and services to meet the patient’s health-care needs, interacts extensively with the care teams to support the clinical roadmap, and works independently under the supervision of the Lead CM team, Supervisor of Case Management, and Manager of Case Management. The intensity of care coordination is appropriate based on patient need and payer requirements, and the Case Manager identifies and resolves barriers that may hinder effective patient care. Position Duties Manages a defined service line patient population to achieve optimal discharge and continuity of care outcomes, promoting sound financial stewardship and patient-family advocacy. Establishes estimated length of stay using MCG criteria and tools. Completes an initial screen of all patients within 24 hours of admission, using MCG criteria to identify needs related to care coordination and/or discharge planning. Develops and implements a comprehensive discharge care plan in collaboration with the clinical care team. Ensures the plan of care is in place with all team members, proactively collaborating with the interdisciplinary clinical care team to document a clear and comprehensive treatment plan, including post-discharge needs. Identifies and facilitates resolution of plan-of-care variances that may impact length of stay. Facilitates referrals to other disciplines and monitors for appropriate follow-up. Maintains ongoing communication with the patient/family and escalates unresolved barriers to timely discharge to Case Management, Manager, or Utilization Management Medical Director. Reviews and analyzes third-party payer denials for in-house patients and communicates with attending physicians, Case Management, Manager, Utilization Management Medical Director, and Utilization Management Nurse per protocols. Engages the interdisciplinary care team, patient, and families in care delivery across the continuum. Reviews the patient daily for appropriate status and goal length of stay per the established Case Management daily prioritization protocol, using MCG criteria and communicates the goal length of stay to the clinical team, patient, and family. Keeps patient discharge information current in EMR documentation, assessing daily status and activities as appropriate, ensuring timeliness of care, and identifying barriers to transition of care or discharge. Participates in interdisciplinary rounds and/or service line rounds with the clinical care team. Reviews the patient daily (Observation and Inpatient) for status and meets admission or discharge criteria, obtaining and reviewing necessary medical reports and treatment plans. Utilizes MCG guidelines/pathways to determine admission status, level of care, goal length of stay, and continued service provision, evidenced by audit of EMR documentation. Documents avoidable days, extended length of stay, authorizations, and denials for medical necessity in SCM and SAM. Communicates to Utilization Management Nurse data supporting denial appeals and informs payers regarding potential denials. Possesses working knowledge of DRG payment methodology and ICD-9/10 coding system. Provides Medicare/Tricare rights and detailed notice of discharge to patient and families. Ensures thorough, early, and ongoing transition/discharge plans, collaborating with patients, families, payers, and providers. Assesses patient for appropriate discharge placement and identifies presumed discharge location on admission. Consults with social services and resources as needs or problems are identified. Communicates transition/discharge plans and problems to other case managers as care is transitioned, ensuring the health-care team proactively makes arrangements and that each plan has clear, attainable goals. Validates that family and patient are aware and understand the discharge plan through documentation and feedback. Ensures education and teaching for family and patient to support transition are begun promptly. When appropriate, performs outpatient and clinic care coordination and monitors patient care as they transition between inpatient and outpatient services. Provides excellent customer service, ensuring all elements of patients’ needs are addressed in the transition/discharge plans. Keeps families and patients involved and informed, as demonstrated by feedback. Responds to emails within 24 hours. Demonstrates clear communication skills with all internal and external customers. Provides excellent service routinely in interactions with coworkers, patients, visitors, physicians, volunteers, etc. Provides unit and team leadership, demonstrating strong, consistent, clear communication and serving as a central point of information to inform physicians on patient status and goal length of stay. Performs miscellaneous job-related duties as requested. Position Qualifications Education Bachelor's degree in Nursing or an Associate degree in Nursing combined with 3 years of clinical experience. (Required) Master's degree in Nursing. (Preferred) Experience Minimum of 1 year of broad clinical experience; care coordination, case management, discharge planning, and utilization review experience preferred. Working knowledge of the financial aspects of third-party payers and reimbursement. (Required) Working knowledge of evidence-based guidelines to manage length of stay. (Preferred) Special Skills Bilingual (Spanish). (Preferred) MCG criteria knowledge. (Preferred) Excellent communication skills, verbal and written. (Preferred) Effective critical thinking skills and ability to anticipate patient discharge needs. (Required) Moderate to expert computer skills. (Required) Effective decision-making/problem-solving skills, creativity in problem-solving, influential leadership skill. (Required) Additional Requirements Current State of Arizona RN license. (Required) Case Management Certification (CCM). (Preferred) Current BLS Certification for Health Care Provider from the American Heart Association. (Required) Valid AZ Department of Public Safety Fingerprint Clearance Card. (Required) Valid Compact State RN License. (Required) Certification / License / Registry Requirements For The Position AZ RN License OR Compact to Arizona License OR Compact State. (Required) Basic Life Support. (Required) Case Management Certification. (Preferred) Fingerprint Clearance Card. (Required) Physical Requirements & Occupational Exposure / Risk Potential Fine motor skills (pinching, gripping, etc) – Occasionally. Hearing – Constantly. Pushing/pulling – Occasionally. Reaching – Occasionally. Sitting – Constantly. Standing – Constantly. Stooping, crouching, kneeling, crawling – Occasionally. Talking – Constantly. Walking – Constantly. Near vision – Constantly. Far vision – Constantly. Use of keyboard, mouse and/or computer equipment – Constantly. Lift up to 35 pounds without assistance – Occasionally. Occupational exposure/risk: inside office environment – Applicable. Occupational exposure/risk: airborne communicable diseases – Applicable. Occupational exposure/risk: bloodborne pathogens or bodily fluid – Applicable. #J-18808-Ljbffr Phoenix Children's