Strength Through Diversity
Ground breaking science. Advancing medicine. Healing made personal.
The Case Manager is responsible for all aspects of case management/ utilization review for an assigned group of inpatients, ED patients and Observation (RETU) patients to determine the correct Level of care (LOC), appropriateness of the admission and continued stay, 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 case manager works collaboratively with physicians, social workers, clinical nurses, home care services, and other members of the interdisciplinary team as needed to develop a plan of care which includes discharge planning, resource management, health education, and the provision of information as it relates to care management and the transition of care.
The Case Manager actively participates in specific clinical initiatives focused on LOC, reducing the length of stay (LOS), improved efficiency and quality and resource utilization. Assignment will be by units/clinical areas of practice and may require responsibility on other units/services.
Responsible for a group of inpatients to determine the appropriateness of the admission and continued stay, 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) and problem solves care transitions accordingly within the interdisciplinary health care team.
- Review and advice for appropriate level of care using criteria sets (refer to designated site software), cases referred or who have Observation diagnosis, or other high risk diagnosis as well as readmissions.
- Review all patients in RETU to insure they meet Observation criteria, assist with discharge or admit to next LOC with-in unit specified timeframes.
- 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.
- Performs continued stay reviews utilizing standardized criteria to justify continued inpatient stay.
- Oversee clinical throughput of patient, ensuring medical treatment plan, e.g., timely tests, consults.
- Collaborates with Physicians and other clinicians to expedite diagnostic testing, treatment and consultations.
- Documents all clinical reviews in using designated site software program.
Supports the mission, vision, philosophy and goals of the Medical Center.
Promotes an environment that is sensitive to cultural diversity and is open and responsive to the diverse backgrounds and experience of others.
- Liaison with Physician Advisor.
- Case Management:
- Assessment of the patient’s clinical, psychosocial, and functional status in collaboration with the interdisciplinary team.
- Identification and documentation of variances affecting the LOS and the discharge planning process.
- Conducts follow-up of any delays in treatment or reporting of results.
- Planning/developing specific goals with the physician, interdisciplinary team, and the patient and/or family.
- Implementation and coordination of specific activities, strategies, and interventions to move the patient through the continuum of care.
- Determine ALC status and track avoidable days.
- Documentation of outcomes achieved and identified internal and external barriers.
- Identifies reasons for readmissions and collaborates with interdisciplinary team on strategies to reduce readmission rate.
- Appropriately identifies and refers cases to the physician advisor to support timely progression of patients along the continuum of care and (appropriate) discharge planning.
- Interacts with patient/family to discuss plan of care and coordination of services based on clinical needs and available resources.
- Utilization Review:
- Maintains a working knowledge of the UR requirements of each payor within the patient population
- Provides the clinical information requested by the managed care companies as part of the concurrent review in a timely fashion.
- Provides clinical information requested by the managed care companies in accordance with contractual agreements.
- Works collaboratively with physicians and managed care companies on concurrent denial appeals
- Communicates clinical information to the payor, as needed, coordinating direct communication between physician and payor Medical Director as required.
- Performs additional duties as assigned.
- Discharge Planning
- Responsible for assessment, communication and monitoring of discharge planning process in collaboration with the clinical nurse initiates the discharge planning process on admission.
- In collaboration with Social worker, obtains authorizations from managed care companies for post-discharge services.
- Assesses for clinical readiness and completes the Hospital and Community Patient Review Instrument (PRI) for patients requiring Residential Health Care Facility placement.
- Assist in having appropriate staff complete discharge forms in a timely manner.
- Coordinates the Discharge Appeal process.
- Liaison with financial department for current insurance coverage.
- Collaborates and participates in concurrent denial and appeals process with all members of the interdisciplinary team.
- Communication and Collaborative Relationships
- Develops and maintains effective working relationships with interdisciplinary team and with managed care/community organizations.
- Interfaces with other departments within the Hospital effectively.
- Demonstrates a professional, courteous and respectful attitude in dealing with patients/families/care givers and members of the health care team
- Educational/Professional Development
- Participates in the development of unit based staff.
- Meets regulatory, licensure and annual health assessment requirements.
- Identifies own learning strengths and needs through ongoing self assessment
- Utilizes learning resources.
- Seeks educational opportunities to maintain and enhance competence within current advances in health care delivery and case management
- Provides presentations and educational offerings as needed.
- Participates in special projects and committees.
- Attends relevant workshops, conferences and seminars
- Demonstrates membership in professional and related organizations.
- Demonstrates competence in case management and required information technology and systems.
- Current NYS RN nursing license.
- Bachelor’s Degree in Nursing required, Masters preferred
- Previous experience in case management, utilization review or discharge planner preferred or a minimum of 4 years’ experience as a RN in an acute care setting.
- Basic knowledge of DRGs.
- Ability to work independently and collaboratively with the interdisciplinary team, patient/family, and others as appropriate. Ability to coordinate, prioritize and allocate resources.
- Case management and or Utilization certification preferred.
- PRI Certification preferred or to be obtained within 1 year.