Clinical Case Manager

SCOPE OF POSITION:

Under the general supervision of the Manager, nurses in the Clinical Case Manager role provide clinically-based case management to support the delivery of effective and efficient patient care. Paces cases from physiological and economic perspectives. Has overall accountability for the utilization management and transition management for patients within the assigned caseload. Ensures the appropriate status and level of care is determined and ensures accurate assessment of medical necessity. Partners with Social Workers and collaborates with the multidisciplinary team to identify appropriate utilization of resources and to ensure reimbursement. With the patient, family and health care team, creates a discharge plan appropriate to the patient's needs and resources.

RESPONSIBILITIES:

1. Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a plan for discharge.
2. Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan. Supports the process of patient choice in establishing a discharge plan.
3. Uses clinical knowledge and knowledge of anticipated response to treatment to assess patient progression towards anticipated outcomes. Communicates and coordinates with the patient/family and health care team to intervene when progression is stalled or diverted. Addresses actual/potential barriers to discharge
4. Completes the interventions necessary for discharges to home with self-care, home with services and short-term skilled nursing facility placement. Assembles necessary referrals, discharge summaries and pertinent information for placement prior to the day of discharge.
5. Actively contributes to, participates in, and follows through on interventions identified in care coordination and complex patient rounds.
6. Identifies high risk patients and creates a collaborative plan to address their unique needs.
7. Key stake holder in the patient throughput process, supports safe and expeditious transition of patients.
8. Utilizes InterQual (IQ), Milliman Care Guidelines (MCG), or in accordance with CMS rules and regulations for medical necessity criteria to monitor appropriateness of admissions.
9. Utilizes appropriate payer criteria to provide recommendation(s) to the attending physician

REQUIREMENTS:

1. Strong interpersonal, communication, and negotiation skills.
2. Ability to form positive, collaborative relationships with hospital staff, patients and families.
3. Ability to effectively negotiate with internal and external providers of patient care services.
4. Analytical abilities to assist in obtaining solutions to problems.
5. Able to work independently and prioritize work.
6. Able to manage multiple priorities.
7. Basic knowledge of computers and clinical applications.
8. Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge.
9. Communicate in a clear, concise, and logical manner in oral and written presentations.
10. Minimum of 5 years of broad clinical experience, predominately in medical/surgical nursing.
11. Case Management, discharge planning and utilization review experience preferred.
12. Licensed as a Registered Nurse in the State of Connecticut.
13. Graduate nursing program (Diploma/Associates) BSN preferred or actively working towards BSN.
14. Case Management certification preferred