RN Case Manager

ABOUT SHERIDAN MEMORIAL HOSPITAL
At Sheridan Memorial Hospital, we proudly rank in the top 13.6% of U.S. hospitals, recognized by the Centers for Medicare and Medicaid Services. With over 850 dedicated employees and 100+ expert providers across 25 specialties, we are committed to exceptional, patient-centered care. Set in northern Wyoming's stunning Big Horn Mountain foothills, Sheridan offers outdoor adventure and community charm. Our hospital combines cutting-edge technology with a collaborative, innovative culture. Join a team that values your skills, fosters growth, and empowers you to impact lives meaningfully. Apply today and be part of Sheridan Memorial Hospital's mission of excellence!

JOB SUMMARY

The overall purpose of the RN Case Manager is to ensure that each patient receives the right care, at the right level of care, at the right time, with a safe and coordinated transition to the next setting, while supporting patient choice, regulatory compliance, quality outcomes, and responsible stewardship of healthcare resources.

The Registered Nurse (RN) Case Manager coordinates patient care across the continuum to promote safe, timely, clinically appropriate, patient-centered, and cost-effective care. The RN Case Manager works collaboratively with physicians, nursing, social work, rehabilitation services, pharmacy, utilization review, post-acute providers, payers, patients, and families.

Within the environment, the RN Case Manager supports appropriate patient status, utilization management, discharge planning, transitions of care, Medicare and payer requirements, and coordination of services including acute inpatient, observation, outpatient, swing bed, skilled nursing, home health, hospice, palliative care, durable medical equipment, and other community-based services.

The RN Case Manager serves as a resource to the interdisciplinary team regarding level of care, medical necessity, discharge planning, barriers to care, payer requirements, and efficient utilization of hospital and community resources.

The goal of the Nurse Case Manager is to educate high risk patients on their diagnosis, disease process and medications, as well as be a liaison with the patient's physician in identifying any potential gaps in care or understanding.

Communicates with physician/manager/co-workers, as appropriate, about changes in the patient's clinical condition, including results of diagnostic studies and symptomatology. Is able to respond quickly and accurately to changes in condition or response to treatment. Additionally, is able to perform general nursing duties in the department with adequate supervision.

Assists Utilization Review and the entire care team, in identifying patients appropriate for admission to inpatient, observation, or other patient care status.

ESSENTIAL DUTIES/RESPONSIBILITIES

Care Coordination and Case Management
Performs a comprehensive case management assessment of assigned patients, including clinical condition, functional status, psychosocial needs, support systems, health literacy, financial or insurance considerations, and potential barriers to discharge. Develops and coordinates an individualized transition and discharge plan in collaboration with the patient, family/caregiver, provider, nursing staff, social worker, therapy services, and other members of the interdisciplinary team. Begins discharge planning early in the hospitalization and continually reassesses the patient's anticipated needs and readiness for transition. Participates in interdisciplinary rounds and communicates barriers, anticipated discharge date, post-acute needs, and actions required to advance the patient's plan of care. Facilitates referrals and transitions to appropriate post-acute services, including: home health, hospice and palliative care, swing bed services, skilled nursing facilities, inpatient rehabilitation, long-term care, durable medical equipment and oxygen, outpatient services, transportation, community and social-service resources. Identifies actual or potential delays in care and works with the interdisciplinary team to resolve avoidable barriers. Promotes patient and caregiver participation in care planning and incorporates patient preferences and goals into transition planning.

Utilization Review and Patient Status
Supports utilization review activities consistent with the hospital's Utilization Review Plan, CMS requirements, payer requirements, and organizational policy. Reviews clinical documentation and available information to evaluate medical necessity, intensity of service, continued stay, and appropriate level of care. Applies hospital-approved utilization management criteria, such as MCG or InterQual, when applicable. Collaborates with providers and utilization review staff regarding inpatient, observation, outpatient, and other applicable patient-status determinations. Identifies cases requiring additional review, physician advisor review, payer communication, or escalation to Case Management leadership. Assists providers and clinical staff in understanding documentation requirements related to medical necessity, patient status, continued stay, discharge readiness, and transitions of care. Supports compliance with applicable Medicare requirements related to CAH inpatient services, including documentation and certification requirements. Identifies potential avoidable days, unnecessary utilization, delays in diagnostic or treatment services, and other barriers affecting length of stay.

Critical Access Hospital Responsibilities
Maintains working knowledge of CMS Conditions of Participation applicable to Critical Access Hospitals (CAH) and incorporates applicable requirements into case management practice. Supports the organization's processes for appropriate CAH inpatient admissions, observation services, outpatient services, swing bed services, and transitions between levels of care. Collaborates with providers regarding the anticipated duration of hospitalization and applicable CAH certification/documentation requirements. Assists with identification of patients who may benefit from CAH swing bed services and coordinates evaluation, authorization, admission, discharge, and transition planning as assigned. Understands the unique challenges of rural healthcare, including limited local post-acute resources, transportation barriers, workforce limitations, geographic distance, and access to specialty care. Coordinates transfers to higher levels of care when services required by the patient are not available locally. Assists with repatriation or return of appropriate patients to the local community when clinically appropriate.

Discharge Planning and Transitions of Care
Evaluates patients for post-discharge needs and potential risk for an unsuccessful transition or hospital readmission. Ensures discharge plans are clinically appropriate, feasible, and consistent with patient goals and preferences. Coordinates post-acute services and communicates necessary clinical information to receiving providers and organizations in accordance with applicable privacy and regulatory requirements. Facilitates patient choice of qualified post-acute providers consistent with applicable Medicare requirements and organizational policy. Coordinates follow-up appointments, medication access, transportation, equipment, services, and other transition needs as appropriate to the assigned case management role. Identifies high-risk patients and supports interventions designed to reduce preventable emergency department utilization and hospital readmissions. Participates in review of readmissions, complex cases, prolonged length of stay, and difficult-to-place patients.

Payer, Authorization, and Denial Prevention
Communicates with payers and payer representatives as required to support authorization, concurrent review, continued stay review, and discharge planning. Provides requested clinical information within established timeframes. Identifies potential authorization or medical-necessity concerns early and escalates issues appropriately. Collaborates with Utilization Review, Revenue Cycle, Health Information Management/CDI, providers, and other departments to prevent avoidable denials. Assists with retrospective review, denial analysis, reconsideration, or appeal activities as assigned.

Medicare Beneficiary Notices and Regulatory Compliance
Maintains knowledge of applicable Medicare beneficiary notification requirements within the scope of the position. Assists with processes for required Medicare notices, as applicable to the patient's status and services, in accordance with hospital policy and federal requirements. Ensures case management activities and documentation comply with CMS, applicable accreditation standards, payer requirements, state and federal regulations, and hospital policy. Protects patient confidentiality and complies with HIPAA and organizational privacy requirements.

Documentation
Documents case management assessment, interventions, patient/family communication, interdisciplinary collaboration, barriers, referrals, payer activity, and discharge planning activities accurately and timely in the electronic medical record. Maintains documentation sufficient to demonstrate progression of the discharge plan and actions taken to address identified barriers. Communicates significant changes in discharge plans, level-of-care concerns, or barriers to appropriate members of the healthcare team.

Collaboration
The RN Case Manager works closely with: hospitalists and attending physicians, emergency department providers, nursing, social work, utilization review, clinical documentation integrity, rehabilitation services, pharmacy, revenue cycle/patient financial services, health information management, home health, hospice and palliative care, swing bed program, skilled nursing and long-term care facilities, behavioral health services, community agencies, third-party payers and utilization management organizations.

Quality and Performance Improvement
Participates in organizational quality and performance-improvement activities related to case management and utilization, including monitoring and improvement of: length of stay, avoidable days, readmissions, discharge delays, post-acute placement delays, denials, patient status accuracy, authorization compliance, timeliness of discharge planning, successful transitions of care, utilization of swing bed and other post-acute services, participates in case reviews, audits, utilization review activities, interdisciplinary committees, and regulatory readiness activities as assigned.

POSITION QUALIFICATIONS - Education / Experience / License and Certifications
Graduate of an accredited school of nursing. Associate Degree in Nursing required; Bachelor of Science in Nursing preferred.
Current, unrestricted Registered Nurse license in the state of Wyoming or applicable multistate compact privilege.
Minimum of 3 years of clinical nursing experience preferred.
Previous experience in acute care, case management, utilization review, discharge planning, emergency nursing, home health, skilled nursing, or other care-transition setting strongly preferred.
HMO, managed care, PPO, Utilization Management/medical management experience preferred.
BLS, required.
Central Registry, required.


Additional Skills
Possess strong clinical judgment, communication, organization, prioritization, problem-solving, conflict-resolution, and critical-thinking skills.
Strong computer skills.
Strong team building and leadership skills.

Specific demands not listed: Possible exposure to blood and or body fluids / infectious disease / hazardous waste requiring the use of Personal Protective Equipment. Exposure to odorous chemicals / specimens and Latex products. Pre-employment drug and alcohol screening is required.

Sheridan Memorial Hospital is an equal opportunity/Affirmative Action employer and gives consideration for employment to qualified applicants without regard to race, color, religion, age, sex, national origin, disability or protected veteran status. If you would like more information about your EEO rights as an applicant under the law, please click here.