Case Manager

Case Manager

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Summary: The Case Manager coordinates the hospital's utilization review activities. Completes CQI Monitors for RM Committee and assures compliance with Federal, State and Third Party Insurance guidelines. Coordinates discharge planning, patient teaching and other associated activities for discharge to nursing facilities or successful community re-entry.

Responsibilities:

• Monitors UR activities/resource utilization
  • Reviews for appropriateness of admission and continued stay
  • Obtains patient precertification to prevent possible payor denials
  • Appropriately follows through with Payor Denials with appeal process
  • Confers with physician and/or refers to physician consultant when "Medical necessity" for admission or continued stay is questioned
  • Completes chart review within 24 working hours and obtains precertification within 48 working hours to appropriately monitor UR activities and prevent payor denials.
• Interviews patients/families and records in Medical Record, Makes referrals
  • Documenting psychosocial, financial, cultural, domestic violence and protective services situations. Refers if necessary.
  • Develops plan to meet needs
  • Provides brief counseling services
  • Completes case findings, assessments, and treatment plans as per policy in order to provide effective intervention.
• Coordinates/promotes patient teaching
  • Provides education and implementation of AMD and DNR, documents to patients as needed
  • Provides and identifies appropriate resources to meet educational needs of staff, patient, physician or community agency
  • Coordinates activities in conjunction with other multidisciplinary team members to meet educational needs.
• Coordinates discharge planning between community agencies, interdisciplinary team, patients/families and physicians
  • Identifies appropriate level of care for nursing home placement/extended care
  • Completes FL2, PASARR approval process
  • Maintains working knowledge of financial and community resource regulations/availability
  • Coordinates continuity of care in order to facilitate transition from LMH.
• Serves as a resource person for families, staff, community agencies and physicians
  • Assists with learning needs of staff
  • Participates in job-related seminars and in service education
  • Serves on hospital committees addressing managed care/length of stay
  • Utilizes resources as appropriate
  • Collaborates with other health care professionals in order to provide comprehensive quality care to patients and families.
• Demonstrates Autonomy
  • Completes tasks as assigned
  • Seeks and accepts additional job responsibilities and learning experiences
  • Sets priorities according to patient needs
  • Operates within parameters of hospital and department policies
  • Demonstrates appropriate time management
  • Seeks opportunities for professional growth
  • Takes personal responsibility and initiative for performance and for professional growth and development.
• Coordinates/promotes patient teaching
  • Promotes education and implementation of AMD and DNR, documents to patients as needed.
  • Provides and identifies appropriate resources to meet education needs of staff, patient, physician or community agency.
  • Coordinates activities to facilitate learning in accordance to needs assessment.
  • Includes patient/family and/or significant other in patient education plan.

Other information:

• EDUCATION
  • Graduate from an accredited school of nursing or Medical Social Worker. Baccalaureate Degree in Human Services area accepted.
• EXPERIENCE
  • Three to four years experience in hospital, nursing home, or community agency.
• LICENSURE/REGISTRATION/CERTIFICATION
  • Certification by American Board of QA/UR or InterQual, Certification in Social Work, Licensed in N.C. for RN or LPN Obtain Case Manager Certification within 5 years.