Lead Case Manager

Lead Case Manager

The Lead Case Manager is a hospital based professional that provides clinically based care management to support the delivery of effective and efficient patient and family centered care in the acute care hospital setting. Responsible for collaboration with medical staff, patients, family and the health care team by assessing, facilitating, planning and advocating for health needs on an individual basis resulting in quality, cost-effective outcomes. Determines realistic goals and coordinates efforts to ensure smooth discharge planning and clear follow up after discharge. Utilizes InterQual criteria guidelines to confirm medical necessity for admission and continued stay. Establishes goals and priorities consistent with the mission and goals of Monument Health, as well as meet requirements of JCAHO and other applicable federal, state and local regulatory and/or accrediting bodies. Collaborates with medical staff and the interdisciplinary team to promote quality patient outcomes.

Monument Health offers competitive wages and benefits on qualifying positions. Some of those benefits can include:

• Supportive work culture
• Medical, Vision and Dental Coverage
• Retirement Plans, Health Savings Account, and Flexible Spending Account
• Instant pay is available for qualifying positions
• Paid Time Off Accrual Bank
• Opportunities for growth and advancement
• Tuition assistance/reimbursement
• Excellent pay differentials on qualifying positions
• Flexible scheduling

Essential Functions:

• Applies up-to-date information related to reimbursement procedures, managed care contracts and patient status in facilitating/collaborating in the plan of care.
• Coordinates the provider aspect of federal/state organization functions as detailed in the Conditions of Participation and other appropriate regulations.
• Supports compliance with Utilization Review and regulatory guidelines. Identify trends related to compliance of regulations and collaborates with appropriate hospital personnel and external agencies to ensure appropriate process changes are implemented.
• Supports the Medical Staff Quality Review process by identification of issues related to quality indicators set forth by the Medical Staff.
• Creates and updates the Plan of Care (POC) to include patient/family-centered goals with interventions that reflect the changing needs of the patient/family unit and is consistent with their current needs and desires.
• Maintains a working knowledge and relationship with community resources and payer benefits that link the individual with the most appropriate resources. Assists by maintaining expertise on benefits, reimbursement and contract/regulation changes per payer guidelines, Medicare and Medicaid to facilitate appropriate reimbursement, education and guidance to assist the healthcare team and patient/family in decision making.
• Facilitates planning for patient/family needs to ensure a smooth transition for the patient across the continuum of care.
• Evaluates current treatment plan to identify barriers, determine realistic goals and objectives, and seek potential alternatives in conjunction with the medical staff. Coordinates team efforts with support services departments to ensure appropriate care and smooth discharge transition.
• Is a visible resource on the unit and coordinates interdisciplinary team huddles/communication, identifying and communicating the patient's health care needs based on the best practice standards to ensure care and communication needs are met in relation to both internal and external providers/services, ancillary department services, core measures, compliance with internal policies/regulatory guidelines and True North metrics.
• All other duties as assigned.

Additional Requirements:

Required: Education – Completion of nursing education program that is approved by a board of nursing or Bachelors/Masters Degree in Social ServicesCertification – Registered Nurse (RN) - South Dakota Board of Nursing or Certified Social Work (CSW) - South Dakota Department of Social Services Preferred:

Education - Bachelors in NursingExperience - 2+ years of Acute Experience; 2+ years of Registered Nurse Experience or for Social Services - 3+ years of Healthcare related ExperienceCertification - Commission for Case Management Certification (CCMC) - Accredited University or accredited training professionals

Physical Requirements:Medium work - Exerting up to 50 pounds of force occasionally, and/or up to 30 pounds of force frequently, and/or up to 10 pounds of force constantly to move objects.

Job Category: Patient Services

Job Family: Care Coordination