Nurse Case Manager

Case Manager

The Case Manager is accountable to facilitate the interdisciplinary team to plan, coordinate, implement and evaluate patient care for assigned service line across the continuum of care. The Case Manager works proactively with the Quality Improvement Teams, patient care standards, Social Work, and utilization management to coordinate the appropriate use of resources to achieve maximum clinical and financial outcomes. The Case Manager participates in maintaining quality care and performance improvement through leadership, problem solving, decision making, and outcome measurement. The Case Manager functions as a resource for the health care team, community, patient/significant others/family and payers by functioning as a clinician, consultant, advocate and educator for assigned service.

Coordination of Care

a. Assists the admission MD and or designated physician and the interdisciplinary teams in assuring coordination of care across the continuum of care in the hospital pre and post-op.

b. Proactively monitor patients' clinical process through patient care standards and evidence based guidelines to ensure timely, appropriate interventions that achieve optimal patient outcomes within appropriate LOS and financial constraints.

c. Provides collaborative care management with the primary nurse in assessing for discharge planning needs, coordinating appropriate resources and evaluating effectiveness of the discharge plan. The discharge planning process needs to begin on admission.

d. Collaborates with the health care team and appropriate department in the management of care across the continuum of care, including pre-admission, discharge, post-discharge, planning length of stay, and utilization of resources.

e. Utilizes own special body of knowledge and evidence based guidelines to provide leadership and guidance to the health care team in formulating an individualized multidisciplinary plan of care to include: pre hospitalization, acute hospital care, discharge education, transition to home and use of community resources.

f. Facilitates and participates in health care team care conference for patients with complex problems.

g. Facilitates patient and family education and the discharge process to promote continuity of care and optimal patient outcomes.

h. Demonstrates experience in the referral process and use of community resources.

Utilization Review

a. Reviews data from admission screening to clarify admission diagnosis, establish appropriate length of stay, and identify any potential outliers and determine appropriateness of admission based on institutional standards and evidence based guidelines.

b. Contacts payer source to confirm/negotiate benefits and provide concurrent reviews. Updated 1/2021

c. Identifies capitated patients to determine appropriate utilization of series and coordinates post hospital care using defined standards.

d. Identifies high-risk patients based on clinical and financial criteria for collaboration with patient financial services to problem-solve available resources.

e. Ensures that appropriate medical/legal documentation is contained in patient's records.

f. Complies with regulations established by third party payers including but not limited to notices of non-coverage reinstatement and continued stay.

g. Follows department UM guidelines.

Quality Improvement

a. Collaborates with the health care team in implementing strategies to reduce length of stay/resource consumption to optimize patient health status for an assigned service patient.

b. Assesses educational needs and provides learning opportunities for health care professionals relevant to particular cases and selected patient care groups.

c. Demonstrates creativity and critical thinking ability in the development of programs or projects.

d. Works with quality improvement team for continuous improvement of patient care outcomes while increasing quality and decreasing cost.

e. Ensure that communication and transmission of documentation occurs with community agencies.

Measurement

a. Collaborates with case management leadership to compile and report aggregate variances and data for specific patient care services

b. Communicates and analyzes aggregate variances with members of the health care team and develops strategies for variance reduction.

Qualifications

1. Registered nurse with a current license in NY State.

2. Bachelor's degree preferred not required

3. Minimum of three years clinical experience in an assigned service. Acute care nursing and case management experience preferred.

4. Recent experience in case management, utilization management and/or discharge planning/home care in a high volume, acute care hospital preferred. PRI and Case Management certification preferred.

5. Demonstrates effective communication, facilitation, and organizational skills.

6. Assertive and creative in problem solving, critical thinking skills, systems planning and patient care management.

7. Self-directed with the ability to adapt in a changing environment. 8. Basic knowledge of computer systems with skills applicable to utilization review process.

Thank you for your interest in Albany Med Health System! Albany Med Health System is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that:

Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.