RN - Case Manager

RN - Case Manager

Utilizes clinical expertise, discretion, and independent judgment in assessing/reassessing, facilitating care coordination, utilization management, and patient advocacy. Responsible for assuring medical appropriateness criteria are met for status and level of care.

• Reviews & analyzes information relative to admission in accordance with Centura policy and documents assessment using case management software and/or other clinical information system.

• Assesses patient's physical, psychosocial, cultural and spiritual needs through observation, interview, review of records and interfacing with patient, physician and interdisciplinary team and caregivers to assist patient/family in making decisions toward next level of care.

• Reviews & analyzes information relative to utilization management when applicable.

• Facilitates discharge planning using case management software, working with patients, families and treatment team making any needed referrals/arrangements and documenting actions.

• Participates in the Performance Improvement process through concurrent chart review and participation on clinical effectiveness teams.

• Documents CM actions taken in EMR.

• Confirms treatment goals and anticipated plan of care through discussions with treatment team/review of documentation.

• Utilizes tools such as guidelines, criteria, or clinical pathways to assist in facilitating plan of care and appropriateness.

• Communicates treatment goals or best practices to treatment team including physician using established criteria/guidelines.

• Assess, coordinates and evaluates use of resources and services relative to plan of care and discusses variances on an as-needed basis with treatment team.

• Communicates modifications in plan of care to treatment team and any needs for further documentation.

• Facilitates family conference meetings on an as-needed basis and documents outcome.

• Participates and/or leads interdisciplinary rounds to facilitate plan of care and discharge.

• Reviews variance in Plan of Care with CM Director/Manager as needed.

• Interfaces closely with Social Worker, Homecare Coordinator, Ambulatory Care Case Manager, Disease Manager, and Utilization Reviewer to ensure seamless and timely delivery of services and avoid unnecessary delays in discharge.

• Maintains updated referral resource lists.

• Identifies when variances occur in anticipated plan of care, tracks for process improvement, and refers to CMO or PA or Third Party Reviewer for peer review as needed.

• Tracks avoidable days using case management software.

• Able to identify and apply evidence based criteria/regulatory guidelines for accuracy in establishing appropriate patient status and level of care. Applies medically necessary validation and may enlist physician advisor and/or Third Party Reviewer.

• Involved with identifying LOS and projected discharge date early in admission and communicate this to the care team.

• Works with third party payers to satisfy utilization review requests and obtain approval of stays.

• Participates in providing information on outliers for length of stay and recommending proactive solutions.

• Participates in denial management with CM Manager/Director with clinical information for denial reversals.

• Performs utilization review in accordance with UM Plan to include concurrent/retro reviews and verify admission/bed status.

• Proactive management of factors influencing length of stay using critical thinking skills minimizing variance days.

• Proactive monitoring of appropriate patient status with interaction with physician for to assure correct order early in admission.

Skills: 1 year of nursing or case management experience Experience working with EMR, preferred Working knowledge of regulatory requirements and accreditation standards, preferred

Float Requirements: -Floating may be required to any Centura location within sixty (60) miles of the original assignment location or Centura-identified "float zone". -Float assignments may include duties outside of original assignment job requirements (including skill set) in accordance with Centura policy.

Education: Associate Degree in Nursing is required. Bachelor Degree in Nursing is preferred. State RN license or RN license from a participating state in the NLC American Heart Association Basic Life Support (BLS)