PayGrade: 98 As a professional nurse, the Case Manager is responsible for the direct Utilization Review and Case Management activities for assigned patient population. The Case Manager performs concurrent clinical review to determine appropriateness of admission, continued need for care delivery, appropriate level of care, and the use of clinical resources in the acute hospital setting. The Case Manager projects the patients post acute care needs and in collaboration with the physicians, social workers, and other members of the health care team and coordinates the arrangements needed to facilitate the discharge. The Case Manager provides clinical updates to claims and insurance personnel to facilitate reimbursement for the delivery of patient care services. Identifies quality and/or risk issues and reports to the appropriate individual/department. The Case Manager is responsible for monitoring and management of metrics to include but not limited to: Length of Stay; Case Mix Index; Denials Management; and Avoidable Days. MSHA expects that every team member will role model Patient-Centered Care behaviors and be guided by MSHA's Values and the Principals of Patient-Centered Care. Every member of MSHA's leadership team is accountable for coaching and monitoring reporting team members to ensure that the standards and initiatives of Patient-Centered Care are a living reality in their work units / Departments. - B. REPORTING RELATIONSHIP
This position reports directly to the Manager of Case Management - C. EDUCATION AND EXPERIENCE (MINIMUM)
- 1) Registered Nurse with current state license.
- 2) Graduate from an accredited school of nursing.
- 3) Emergency Department experience highly recommended.
- 4) Three (3) to five (5) years acute medical/surgical or specialized clinical area experience required.
- 5) Prior utilization/quality and case management experience highly preferred.
- 6) A Certification in Case Management within 3 years preferred.
- 7) Demonstrates the following attributes:
- a. Excellent interpersonal communication and networking skills.
- b. Excellent critical thinking, discernment, and clinical assessment skills.
- c. Ability to develop rapport with multiple health care disciplines and providers across the continuum of care.
- d. Ability to relate well and establish partnerships with the physicians to maximize quality of care for patients through the appropriate use of resources.
- e. Ability to develop, implementation, and evaluate discharge plans.
- f. Ability to perform effectively in team situation.
- g. Ability to work independently, utilizing time constructively and organize workload for maximum productivity.
- h. Basic computer skills
- 1) Job Responsibilities and Job Knowledge: Meets the expectations and assumes accountability for all ongoing job responsibilities. Balances unexpected tasks while performing ongoing job responsibilities under ordinary direction and minimal supervision. Current and proficient on job-related knowledge, skills, and industry changes. Demonstrates understanding of job relative to hospital operations.
- a. Consistently performs work assigned in accordance with all departmental, hospital, and regulatory agency policies and procedures.
- b. Screens assigned caseload for appropriateness of admission utilizing established criteria and performs ongoing clinical review to determine the necessity for continued stay and appropriate level of care.
- c. Collects and reviews patient assessment data, within established timeframes, identifies the individual's discharge planning needs related to the medical diagnosis, treatment options, financial resources, and environmental factors.
- d. Initiates a discharge plan, in collaboration with the patient/family and healthcare team establishes mutually set goals that are clinically desirable, and are financially feasible.
- e. Appropriately identifies and refers cases that need the interventions of the Social Worker. Provides pertinent information regarding patients and family's psychosocial status and needs.
- f. Identifies delays in care, quality and risk issues then communicates information to appropriate individuals and departments.
- g. Serves as a resource for staff and physicians by providing both written and verbal communication about discharge planning, appropriate utilization of resources, and alternatives for care and service as appropriate.
- h. Maintains accurate and timely documentation of case management activities to assure that physicians and caregivers are well informed regarding the discharge plans. Adheres to all policies and procedures regarding documentation and confidentiality of information.
- i. Performs timely clinical reviews for third-party payors to facilitate reimbursement for patient care services. Effective in role of liaison between third-party payors, the patient, and the physician.
- j. Contact's patient's insurance company as soon as initial assessment has established post-discharge needs. Documents needs and provides patient benefit information to enable the development of a discharge plan.
- k. Working knowledge of available community resources for access in meeting individual patient needs. Network with peers and community representatives to keep informed of new facilities and services.
- l. Maintains knowledge of regulatory agency requirements for discharge planning, admission criteria for alternate levels of care and the Medicare and Medicaid reimbursement methods for the different levels of care. Completes forms necessary to access various state and federal services and qualifying programs.
- m. Other duties as assigned.
- 2) Fiscal Responsibility: Consistently, accurately, and completely performs all job responsibilities. Efficiently demonstrates cost consciousness by organizing work processes within established deadlines, and using supplies, equipment, and time according to budgetary guidelines.
- a. Communicates patient's progress towards treatment goals to third-party payors in order to facilitate high-quality, cost-effective patient care, within appropriate timeframes.
- b. Demonstrates organization and efficiency in the performance of job responsibilities and consistently utilize time productivity.
- c. Understands and utilizes strategies for managing care delivery and clinical resource consumption within the managed care population.
- d. Comprehends and informs the manager of new theories, practices, or methodologies in case management activities that may be required to meet budgetary guidelines and improved hospital performance.
- 3) Communication: Consistently provides accurate and timely information while listening effectively. Using positive communication skills, shares information clearly and concisely. Proactively disseminates information to keep others informed on key issues and situations.
- a. Communicates effectively with community and agency representatives, conveying a positive, cooperative, and professional image.
- b. Conveys support of the organization's objectives, decisions, and policies.
- c. Consistently communicates patient information to the healthcare team, both written and verbal, to promote
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