RN - Case Manager

Clinical 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.

Job Responsibilities:

• 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)