Case Manager RN

The RN Case Manager (RNCM) will be responsible for all aspects of case management for an assigned group of patients to determine the appropriateness of the Level of Care, assist in the development of the plan of care; ensure that the plan is implemented in a timely basis and identify the expected length of stay (ELOS). The RNCM participates in the Utilization Review, Discharge Planning, Risk Management, and Quality Assessment and Performance Improvement activities of the Department of Case Management.  Assesses, plans, coordinates, implements and evaluates patient’s health care needs throughout the continuum of care with a focus on efficient quality care while minimizing risk to patients, families, staff and Hospital. The RNCM supports the mission, vision, philosophy and goals of Calvary Hospital.

ESSENTIAL JOB FUNCTIONS :

1.      Reviews all new admissions to identify patients where utilization review, discharge planning, and / or case management will be needed using standardized criteria to achieve optimal patient outcomes and appropriate reimbursement for the organization.

2.      Performs continued stay reviews utilizing standardized criteria to justify continued inpatient stay.

3.      Collaborates with Physician and other clinicians to expedite diagnostic testing, treatment and consultations. Documents all clinical reviews in Case Management Documentation system.

4.      Conducts concurrent and retrospective reviews of the medical record to assess patient care for quality, utilization, risk, discharge needs and to collect data as required to support Hospital functions and research studies.

5.      Consults and collaborates with the physician and other healthcare professionals to assure accurate and timely documentation of patient progress towards expected clinical outcomes so that goals of the care plan are appropriate.

6.      Assessment of the patients clinical, psychosocial, and functional status in collaboration with the interdisciplinary team.

7.      Carries out discharge planning functions, identifies and documents variances affecting the LOS and the discharge planning process, and any  opportunities for change in level of care. Plans / develops specific goals with the physician, interdisciplinary team, and the patient and / or family.

8.      Includes the patient / family in the decision-making process regarding the patient’s hospitalization and discharge planning process with focus on quality care and / or cost benefit to patients consistent with payer, provider, and consumer expectations.

9.      CM ensures implementation and coordination of specific activities, strategies, and interventions to move the patient through the continuum of care. Documentation of outcomes achieved and identified internal and external barriers.

10.  Assures the continuity of care post-discharge by coordinating and assisting patients to obtain appropriate medical follow-up and meet other healthcare or psychosocial needs, and by providing pertinent medical information to the healthcare provider and by providing patients / families with information on available resources. Conducts follow-up phone calls to discharged patients as appropriate.

11.  Takes appropriate actions to identify and facilitate resolution of barriers in hospital and out of hospital services through the PI process; arranges, attends and participates in meetings as required.

12.  Utilization Review :

a.       Maintains a working knowledge of the UR (Utilization Review) requirements of each payor within the patient population;

b.      Provides the clinical information requested by the managed care companies as part of the concurrent review in a timely fashion.

c.       Provides clinical information requested by the managed care companies in accordance with contractual agreements.

d.      Works collaboratively with physicians and managed care companies on concurrent denial appeals

e.       Communicates clinical information to the payor, as needed, coordinating direct communication between physician and payor Medical Director as required.

13.  Discharge Planning :

a.       Responsible for assessment, communication and monitoring of discharge planning process.

b.      Obtains authorizations from managed care companies for post-discharge services.

c.       Assesses for clinical readiness and completes the Hospital and Community Patient Review Instrument (PRI) for patients requiring Residential Health Care Facility placement.

d.      Liaison with financial department for current insurance coverage.

e.       Collaborates and participates in the appeals process with all members of the interdisciplinary team.

14.  Responds to payer’s requests for patient medical information while respecting patient confidentiality by judiciously sharing only that information relevant to his / her care and within requirements of law.

15.  Assists physicians, patients and families in responding to payer and regulatory agencies concerns regarding utilization, reimbursement and quality issues.

16.  Communicates identified issues relating to quality, utilization, risk and discharge planning to the Department Director.

17.  Maintains working knowledge of regulatory and accrediting agencies’ standards (such as Joint Commission, NYSDOH, IPRO Medicare / Medicaid) and the unique requirements of all reimbursement systems.

Requirements

• Registered professional nurse, currently unencumbered NYS licensure.
• Bachelors in nursing or health care related field preferred.
• Qualified PRI Assessor required.
• Five (5) or more years experience in either Utilization Management, Quality Assessment and Improvement, Risk Management, and / or Discharge Planning required, and 5 years Medical / Surgical or Oncology Nursing preferred.
• Excellent interpersonal skills; ability to relate well to peers as well as those in varying levels of authority.
• Attentive to details and ability to provide meticulous and concise information and reports.
• Ability to work independently.
• Ability to work effectively with the Medical Staff and other clinical disciplines.
• Basic Computer skills.
• Demonstrates knowledge of the age of the patient population served from adult to geriatric in the performance of job duties and responsibilities.
• Exhibits an ability and attitude relative to the spirit of caring and tradition at Calvary Hospital as required by specific job duties and functions.