RN Case Manager

Reports to: Chief Nursing Officer (CNO)
FLSA Classification: Full-time, Not Exempt, Hourly

Medical Center Case Manager / Discharge Planner / Utilization Review, Registered Nurse (RN) is responsible for compliance with CMS Conditions of Participation including implementation and annual review of the Utilization Management Plan and coordination of the Utilization Management Committee. The Case Manager follows the hospital's Case Management/Utilization Program that integrates the functions of utilization review, discharge planning, and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated, cost-effective resources. This position provides a collaborative practice to improve quality through coordination of care encompassing length of stay, minimizing cost, and ensuring optimum outcomes.

Essential Functions

Promote the mission, vision, and values of the organization.
Interview patients to identify their requirements and assess their need for psychosocial, medical, or psychiatric treatment.
Initiate ongoing communication with the patient and the patient's family to assess discharge needs starting upon admission.
Complete assessment for most suitable care plan including but not limited to; transitions/discharge planning needs and risk for readmission.
Facilitate interdisciplinary team meetings that foster collaboration with the patient, their family and the healthcare team as deemed necessary, this includes multidisciplinary meetings and Utilization Review/Case Management meetings. Provides input in such meetings regarding utilization management and discharge planning.
Assist in coordinating the activities of all health care professionals responsible for patient needs, to ensure they work toward a common goal.
Communicate with physicians and providers to ascertain plans for timely discharge.
Responsible for home care needs being met by the time of discharge, with a goal of arrangements and referrals completed 24 hours prior to discharge with date of discharge is known.
Runs an effective and efficient Inpatient Interdisciplinary Huddle, assuring that all members of the healthcare team are participating, communicating and working toward a safe and successful discharge.
Manage and collaborate with the healthcare team to decide if an alternative level of care is appropriate within 24-48 hours, including but not limited to; Admission, Observation, Inpatient, Swing Bed status and complete MDS documentation as necessary.
Communicates daily with admissions personnel regarding admissions and discharges.
Assist as needed with obtaining referrals, prior authorizations for Home Health Care, DME, SNF, acute rehab and appointments.
Provide education and training for healthcare professionals to improve their knowledge of case management techniques and to enhance their skills and knowledge.
Cooperate with insurance companies, based on information received and document communication and clinical data to third-party payers.
Review for medical necessity (discuss with admitting provider if medical necessity criteria is met; escalate to Physician Advisor / secondary reviewer as indicated)
Verify status order and certification.
Knowledgeable of criteria for Medicare, Medicaid, HMO and private insurance coverage and assessment of the patient's health insurance plan and work with the insurer and providers to ensure that the best care is delivered with the least financial burden.
Complete concurrent medical necessity reviews as required or a minimum of every 48 hours for all payers (if appropriate, escalate to secondary reviewer if lack of medical necessity).
Evaluate IMM, MOON and NOMNC notice delivery process to ensure consistent compliance.
Issue HINNs as appropriate.
Ensure that a quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting the data to the appropriate location; reports and identifies data that indicates potential areas for improvement of care and services provided within the system.
Develop and implement methods, policies and procedures to improve departments' efficiency and overall effectiveness.
Review all concurrent denials with Attending for additional information. Refer to secondary reviewer as appropriate.
Collaborate with peers in Medical Management, Quality Management, Grievance and Appeals.
Implement and manage effective Utilization Management processes that results in cost efficient utilization of services.
Reviewing patient records to identify areas where clinical staff can improve skills, documentation, identify patterns in diagnosis and treatment to improve their skills.
Manage pre-authorization, concurrent review, and retrospective review process for all inpatient, outpatient services.
Log all secondary reviewer referrals and outcomes.
Participate in revenue cycle meetings.
Perform and oversee needs analysis and planning. Work with executive leadership to ensure targets are met for the annual operating plan/financial management.
Other duties as assigned.

Required Education and Experience

Current, unencumbered nursing license required.
Minimum of 5 years Nursing Experience in Hospital required.
Knowledge of Critical Access Hospitals required.
Knowledge of Swing Bed Programs required.
Bachelor's Degree and Master's Degree preferred.
Previous experience with word processing and excel preferred.

Skills and Expectations

Kind and professional demeanor.
Knowledge of nursing services and insurance coverage preferred.
Strong organizational and interpersonal skills.
Ability to determine appropriate course of action in more complex situations.
Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive work attitude.
Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work.
Ability to maintain confidentiality of all medical, financial, and legal information.
Ability to complete work assignments in an accurately and timely manner.
Communicate positively and effectively, both written and verbally.
Ability to hand off difficult situations involving patients, physicians, or others in a professional manner.
Knowledge of the continuum of care and utilization process.
Ability to document Case Management plans in a clear concise manner.
Demonstrate effective organizational skills in an evolving environment.
Work with honesty, compassion and integrity at all times.
Adherence to ALL procedures and policies.
Demonstrate a commitment to building and sustaining a diverse, inclusive, and equitable working environment.

Physical Requirements
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing this job, the employee:

Must be able to remain in a stationary positon 50% of the time.
Must be able to move and traverse about the facility 50% of the time.
Frequently transport objects weighing up to 50lbs
Occasionally position objects weighing up to 100lbs.
Must be able to communicate and exchange information in a way others will understand.
Must be able to recognize details such as color and depth within a few feet of the observer.
Frequently operates computers, machinery, and other healthcare equipment.
Constantly positions self to complete essential functions.
May be required to wear N95s or PAPRs up throughout the shift.

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