CARE MANAGER - RN - CASE MANAGEMENT
Status: PRN - As Needed
Shift: Varied 8/12 hour shifts. May include nights/weekends/holidays.
The RN Case Manager works collaboratively with patients, nurses, social workers, physicians, other practitioners, caregivers, and the community to facilitate care along a continuum with the goal to achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient’s right to self-determination.This is done within the Standards of Practice and Scope of Services as defined by the American Case Management Association.
Graduate of a RN program.
Rgistered Nurse licensed to practice in the State of
A Minimum three years of clinical nursing, case management and/or utilization review experience.
Emergency services and/or utilization review/case management experience preferred.
Knowledge of established medical necessity criteria and their application preferred.
Knowledge of Medicare, Medicaid, Managed Care Organizations, Social Services, discharge planning, community resources, and referral agencies strongly preferred.
Knowledge of ICD-10 coding, Case Mix Index monitoring, and legal compliance, and clinical documentation preferred.
Knowledge of Peer Review and payer functions preferred.
Knowledge of third party payor appeal process preferred.
Knowledge of Quality Improvement activities/Team Leader/Facilitator training preferred.
ALL CARE MANAGERS:
A.Contributes to the development of a goal-directed, age-appropriate plan of care through an interdisciplinary team process.
B.Assesses patients’ biophysical, psychosocial, environmental, economic/financial, and discharge planning needs to assist in the development of patient-centered goals of care. Plans for barriers to effective transitions of care.
C.If needed, procures services and resources, serving as an advocate for patients and families.
D.Communicates patient needs and follows up with appropriate professionals (i.e., Social Worker, clinical pharmacist, diabetes educator, and dietician).
E.Assesses the appropriateness and timeliness of the level of care, diagnostic testing, clinical procedures, quality and clinical risk issues, and documentation completeness.
F.Communicates continually with physicians, patients, caregivers, and care team members to facilitate coordination of clinical activities to enhance a seamless transition from one level of care to another.
G.Seeks information and resources for use in creative problem solving for complex discharge planning, quality of care, and utilization issues.Explores new resources when opportunities for the patient are absent or in short supply.
H.Works collaboratively with other departments and services to define and study areas of inefficiency to participate in process improvement projects.
I.Studies available information to remain abreast of reimbursement modalities, community resources, review systems, and clinical and legal issues that affect patients and providers of care.
J.Serves as a resource and provides education to physicians, patients, caregivers, and professional staff on levels of care, quality of care issues, and regulatory concerns.
K.Provides orientation and mentoring to new staff members.
L.Fosters positive internal and external customer relations.
M.Works in accordance with applicable state and federal guidelines and with the unique requirements of reimbursement systems.
N.Knowledgeable about and acts in accordance with laws and procedures regarding patient confidentiality and release of information, Americans with Disabilities Act, other laws protecting rights, and worker’s compensation laws when applicable to the care manager’s practice.
O.Performs other duties, projects, or subjects as assigned by departmental leadership.
P.Follows Infection Control policies and procedures at all times per system guidelines.
Q.Follows North Oaks Health System’s Compliance Programs and Federal and State regulatory guidelines.
R.Coordinates transitions in care with payer source to minimize financial impact to patient/family and organization.
S.Reviews physician orders to ensure appropriate level of care orders are in the medical record.
UNIT-BASED RN CARE MANAGER:
- Makes daily rounds to assess hospital inpatients.If possible, makes rounds with attending physician(s).
- Participates in interdisciplinary staffing meetings on behalf of the patient and physician.
- Collaborates daily with physicians and care team members to support the assessment of continued need for acute care hospitalization services.Utilizes available established criteria and documents findings in EMR.
- Communicates weekly to the department Manager/Director the discharge plan of any patient with a length of stay greater than five days.
- Advocates for the patient, family, physician, and facility to obtain benefits from insurance carriers and others with the Utilization Review personnel.
- Monitors and assist physicians with documentation compliance of core/quality measures.
- Immediately reports to the Manager, Director, Physician Advisor and/or CMO any case not meeting continued stay criteria.
- Provides Manager/Director with updates on any situation where the patient transition from one level of care to another is not proceeding as expected.
- Reviews record of all patients in observation status on assigned area daily to establish proper start time and end time for observation services
- Communicates with the attending physician regarding the appropriate level of care placement based on the physician’s determination and documentation.
- Communicates level of care status changes to Insurance Verification personnel for appropriate notification of payer source.
- Completes criteria reviews on all observation patients daily and new inpatient admissions to determine medical necessity, discusses with the Attending Physician, and documents results.
- Communicates patient needs, physician orders, and other pertinent information to any continuing care providers to facilitate a safe transition to another level of care.
EMERGENCY DEPARTMENT RN CARE MANAGER:
A.Performs initial clinical review on patients being admitted utilizing established clinical guidelines. Documents reviews and pertinent findings in the UR tab of the EMR.
B.Communicates outcome of admission screens based on established criteria for medical necessity to the Medical Staff.
C.Provides recommendations for alternative levels of care when appropriate, based on established clinical practice guidelines.
D.Serves as an information resource regarding insurance benefits and coverage to patients, caregivers, hospital and Medical Staff on admitted patients.
E.Refers cases which do not meet established admission criteria to department Manager/Director, ED Medical Director and/or Physician Advisor/Asst. Chief Medical Officer.
F.Serves as “on-call” Case Manager for the hospital after normal business hours.Manages inter-facility transfers.Refers requests for post-discharge referrals to community agencies to the Social Worker II assigned to the ER, when present.
G.In the absence of a Social Worker:
a.Assesses and documents patients’ discharge planning needs, making appropriate referrals.
b.Reports suspected abuse, neglect, and/or exploitation to appropriate agency and/or law enforcement.
c.Works to place PEC/CEC patients for psychiatric treatment needs and updates the Coroner as needed.
H.Obtains appropriate information and facilitates Ed-to-ED transfers by working with ED Medical Staff.Maintains a comprehensive log of all Ed-to-ED transfer requests.
I.Assists Social Worker with identifying trauma patients.Works with available resources, such as EMS and law enforcement, to locate family for notification as needed.
J.In absence of a Bed Flow Nurse:
a.Collaborates with all hospital personnel to determine appropriate patient placement and bed assignment.
b.Manages inter and intra-facility transfers, direct admissions, and status changes twenty four hours per day, seven days per week
c.Acts as a contact for physician office personnel planning for Direct Admissions, and outside facility transfers.
d.Reviews daily admission list to ensure all initial clinical reviews were performed onprevious days’ admissions.Audits for appropriate medical necessity / status placement
e.Completes and communicates daily bed / patient flow plan by 4:30am and 4:30 pm.