Case Manager

Case Manager

The Case Manager works under the direction of the clinical director of care management providing coordination of care for patients at Luminis Health to support safe seamless timely transitions across the continuum. Utilizing a collaborative process will identify assess plan implement and evaluate the options and services required to meet an individual's health and health related needs including social- determinants that affect one's overall wellbeing. Promotes the right resources at the right time and at the right level of care and is responsible for engaging and supporting patients that are in need of care management services is able to determine using evidence based guidelines the correct initial and ongoing level of care for patients and is able to submit appropriate denial review for Medicare Medicaid and commercial insurers.

Essential Job Duties:

• Identifies and prioritizes patient in need of care management services using a holistic approach inclusive of biopsychosocial functional cultural spiritual and financial factors uses a multi discoplinary approach to assess/plan for care needs.
• Identifies and implements strategies such as motivational interviewing to promote patient engagement self-care treatment adherence and optimal levels of health and well-being.
• Utilizes evidenced based guidelines (such as InterQual or other agreed upon evidenced based guidelines) to promote quality care decrease variation and mitigate waste. Verifies appropriate level of care enters clinical review and authorized days in Epic documents actions to avoid denied days refers cases to Physcian Advisor as appropriate.
• Manages observation stay patients assertively and ensures timely testing treatment and conversion to inpatient status or discharge.
• Develops and coordinates transition plans for patients transitioned to home with home health community care coordination program Hospice or Palliative care home infusion and routine sub-acute and skilled post-acute providers completes all necessary documentation and necessary handovers. Involves and prepares patients and families for transition from the ED Peds Clatanoff or Observation unit as indicated.
• Maintains clear and concise documentation in each patient record to reflect physical and functional limitations psychosocial characteristics educational needs of patient & family family/social support systems financial economic and transition needs. Initiates referrals to disciplines as indicated.
• Participates in nursing unit and department clinical outcome projects as well as process improvement initiatives of care management.
• Identifies potential or current patient situations which require referral to other members of the health care team such as infection control risk management or quality management. Assures plan of care is adjusted as appropriate and that follow-up occurs. Keep leadership abreast of potential issues.
• Utilizes all risk and predictive analytic tools such as the readmission risk tool. Applies tailored interventions to mitigate potential barriers or risk prolonged unnecessary hospitalization and readmission prevention.
• Maintains compliance with all regulatory standards (CMS commercial insurers etc)

Educational/Experience Requirements:

• Graduate of an accredited school of nursing BSN Program
• Three years of experience in a clinical setting ambulatory or post-acute.
• Care coordination experience preferred.
• Current licensure as a registered nurse by the Maryland Board of Nursing.

Working Conditions Equipment Physical Demands:

There is reasonable expectation that employees in this position will be exposed to blood-borne pathogens. Physical Demands - Medium work. The physical demands and work environment that have been described are representative of those an employee encounters while performing the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions in accordance with the Americans with Disabilities Act.