A clinical position that works within a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options of care, services and alternative levels of care to meet an individual’s needs and facilitate appropriate discharge and length of stay. By assuming a leadership role with the interdisciplinary team, the Case Manager promotes appropriate utilization of care and services, and cost effective outcomes. The Case Manager is responsible for Utilization Review, of the medical record to ensure care and services are delivered timely and appropriately. This positions is responsible to reduce and/or eliminate avoidable days..
Nature and Scope
The Case Manager has the responsibility to promote case management activities through the health continuum, beginning in the acute setting. Case management begins with the assessment of pre-morbid health status, current medical condition and post-acute needs. The Case Manager works closely with the Bed Day RN who performs admission and concurrent continued stay reviews, together they ensure that services are being delivered at the most appropriate level of care to meet the client’s needs and to secure reimbursement from payers.
Utilizing an interdisciplinary team approach, the Case Manager acts as a consultant and educator on matters referring to alternative levels of care and managed care issues,. In collaboration, to provide optimal patient care through, assessment, planning, implementation, and evaluation of neonatal, pediatric, adolescent, adult, and geriatric patients and families. This position also provides information such as certified LOS and reimbursement issues to physicians as needed to ensure the appropriate and timely disposition of the client to the next level of care. The Case Manager monitors and documents the progress of the plan, making revisions as needed, to assure a smooth transition to the next level of care at the time of discharge.
Specifics of Positions:
· excellent documentation and communication skills and must be able to use critical thinking, find solutions quickly and be comfortable escalating when services or care are not delivered efficiently or appropriately.
- Attending rounds and ensure
- All orders written
- DC plan is in place and in computer
- Social Workers are assigned to appropriate patients
- Choice forms (When needed) and IMMs are signed 48 hours prior to DC
- All are in agreement with DC plan, date of DC and plan for care transitions
- Review charts and ensure
- All orders are written and signed and follow up with physicians (Hospitalist, UNR, Surgeons)
- Face to Face documentation is done
- DC summaries are written and in system in time for DC
- Ensure all tests are scheduled timely and escalate as needed
- LOS does not extend beyond what Bed Day Management review states is appropriate and ensures everyone on care team is working to DC timely
- Clinically Complex Cases are worked up appropriately for DC needs (wound vac, IV meds, Meds Requiring Pre Approval etc..)
· The Case Manager must respect beliefs and values while advocating for the client’s right to self-determination and to make informed choices.
· The Case Manager documents all chart and phone reviews, identifies and communicates potentially avoidable/non-reimbursed days, quality indicators (such as re-admissions) and core measures. As indicated, delivers non-coverage letters as set forth by payer and/or regulatory compliance.
· The Case Manager acquires and maintains knowledge and competencies related to the expectations of their position including an extensive knowledge of post-acute admission criteria (Rehab, LTAC and SNF etc.). Practice is aligned with the mission, vision and goals of the Integrated Health System. She/he participates in Quality Improvement initiatives.
· This position does not provide patient care.
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Requirements – Required and/or Preferred
Must have working-level knowledge of the English language, including reading, writing and speaking English. Appropriate education to obtain and maintain State of Nevada Registered Nurse licensure. Bachelor of Science in Nursing preferred.
One year experience preferred as an RN. Case Management, Post-Acute experience and/or UR/QA experience preferred.
Ability to obtain and maintain a State of Nevada Registered Nurse license
National Certification (i.e. Case Management (CCM), Professional Utilization Reviewer (CPUR), or Managed Care (NMCC)) preferred. Current BLS/CPR certification required.
Computer / Typing:
Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.