Clinical Case Manager

Summary:

Is responsible for coordinating delivery of services to managed care residents in collaboration with the facility's team members. Monitors and documents the cost effectiveness of treatment provided, facilitates and coordinates the admission and discharge process, serves as the resident and family advocate and acts as a liaison to insurance and medical management professionals.

Essential Duties and Responsibilities:

1. Demonstrates commitment to company's mission, values and standards of ethical behavior

2. Models a positive and professional image that emulates the organization's mission and encourages a spirit of cooperation with co-workers. Provides assistance to co-workers and promotes teamwork by sharing information useful to achieving desired results.

3. Ensures that each resident receives superior care in a manner that maintains or enhances their quality of life and helps them attain and maintain the highest possible mental and physical functional status, in an environment of kindness, dignity and respect.

4. Ensures that all residents' rights, including fair and equitable treatment, self-determination, individuality, privacy, property and civil rights including the right to voice complaints are well established and protected at all times.

5. Complies with all company and departmental policies and procedures

6. Ensures thorough and timely communication with managed care/insurance case managers to coordinate certification and concurrent stay programs.

7. Negotiates with payor representative proper compensation for services to be delivered in areas such as use of generic medications, alternate medication delivery routes, and exclusions to ensure appropriate level of care as well as cost effectiveness.

8. Communicates resident status, change in function and care plan either by phone or written report to payors.

9. Includes payor representative in interdisciplinary meetings if requested or deemed necessary to promote payor/provider relationship.

10. Documents all payor interactions regarding resident progress, expected outcomes and reporting capabilities including special instructions.

11. Maximizes benefits by coordination of cost effective care, avoiding fragmented care and duplication of services and ensuring the appropriate level of quality care is provided in the most suitable setting.

12. Participates in all managed care resident interdisciplinary meetings to coordinate services to ensure that the resident's total regimen of care is maintained.

13. Works with team members to ensure discharge planning goals and objectives are developed and discussed at the interdisciplinary team meetings.

14. Assists in planning the services required in the resident's discharge plan as necessary.

15. Maintains communication with facility business office and medical records to ensure accurate census and payment of managed care residents.

16. Performs random charting audits to ensure accurate and thorough documentation to support reimbursement of services rendered.

17. Reports problem areas to department directors.

18. Assists with contract negotiations as necessary.

19. Participates in the admission process including pre-admission assessment, rate negotiations, benefit verification care needs and reporting.

20. Assists interdisciplinary team in planning for admission and ensure staff are adequately prepared to meet needs of the managed care resident on admission.

21. Participates in marketing functions as deemed appropriate to assist with increasing managed care census.

22. Assists with completion and filing of recordkeeping forms/charts upon admission, transfer, and/or discharge of the managed care resident.

23. Assists in arranging for diagnostic and therapeutic services, as necessary.

24. Completes assigned sections of minimum data set (MDS), and coordinates accurate and timely completion and revision MDS including the implementation of CAAs, Triggers and care plans on managed care residents. Ensures that assigned residents' care plans accurately reflect appropriate goals, problems, approaches, and revisions based on resident needs.

25. Ensures that appropriate supplies and equipment, etc., are available to meet the needs of assigned residents.

26. Reports the following in accordance with established facility procedures and regulatory standards: accidents and incidents; resident grievances, complaints, allegations of resident abuse and/or misappropriation of resident property; occupational exposure to blood, body fluids, infectious materials, and hazardous chemicals; concerns and suspected incidences of non-compliance including but not limited to hazardous conditions and equipment.

27. Adheres to state and federal regulations and company policies and procedures; HIPAA confidentiality standards of resident and facility information; OSHA and safety standards; and established safety precautions and regulations (including use of mechanical lifts when lifting or moving heavy individuals or objects) in the performance of tasks and the use of equipment and supplies.

28. Attends orientation, in services and meetings as required. Participates in OSHA and CDC in-service training programs for hazardous communication, TB management, and blood borne pathogens standard. May participate in workshops and seminars to stay current with changes in field, as well as to maintain professional status. Takes responsibility for staying updated on new regulations, best practices and internal policies and procedures.

29. Demonstrates knowledge of facility and departmental quality improvement activities. Recommends to Supervisor any equipment and supplies needed for department as well as any departmental improvements.

30. Utilizes most efficient, safe and cost effective techniques and methods, and uses supplies and equipment in most efficient manner to minimize waste.

31. Participates in and assists in departmental studies and projects as required.

32. Performs other related duties as required.

Knowledge and Skills:

1. Ability to represent Company in an ethical and professional manner, and to maintain accountability

2. Ability to interact tactfully, effectively, and professionally with other employees, visitors, government agencies/personnel and the general public, as needed

3. Ability to understand and follow applicable regulations, policies and procedures fully and consistently

4. Strong interpersonal and communication skills, both one-on-one and in a group, and ability to listen and respond to questions effectively

5. Willingness and ability to function as an effective team member through good communication and cooperation to meet departmental goals

6. Must demonstrate flexibility and ability to adapt to change

7. Ability to organize, prioritize and meet deadlines

8. Ability to maintain confidentiality and be discreet

9. Must be able to multi-task and handle pressure

10. Must be able to follow instructions and to accept feedback

11. Must successfully pass background check, health exams, and any other pre-employment requirements

12. Must be able to operate departmental equipment, as appropriate

13. Willing to work beyond normal working hours, weekends, holidays, and/or on other shifts and in other positions, when necessary

14. Strong written and verbal communication skills in English required to perform essential job functions

15. Must have strong detail orientation, high accuracy level, and legible handwriting

16. Creative problem solving abilities

17. Ability to inspire trust and respect, and mobilize others

18. Ability to exercise discretion and independent judgment, and reach logical, practical decisions

19. Ability to think strategically, master change, and maintain future orientation

20. Sufficient computer skills including proficiency in Microsoft Office, Outlook, and /or Internet to perform required duties.