RN - Case Manager

RN - 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.

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)