The Case Manager (CM) will be responsible for all aspects of case management for an assigned 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). The CM works collaboratively with physicians, social workers, clinical nurses, home care services, and other members of the interdisciplinary team as needed. The CM actively participates in specific clinical initiatives focused on reducing the length of stay (LOS), improved efficiency, quality and resource utilization. Assignment will be by units/clinical areas of practice and may require responsibility on other units/services.
Duties and Responsibilities:
1. Reviews all admissions and continued stay for assigned group of inpatients to determine appropriateness utilizing standardized criteria (Milliman/Interqual) to achieve optimal outcomes and reimbursements. Identify variance, avoidable days and address readmission reasons timely.
Enter working appropriate DRG -for ELOS determination
Document external/internal barriers and outcomes.
2. Based on clinical expertise,assist in the development of plan of care and ensure that plan is implemented timely. Discuss with team where delays are identified; provide direction, assistance and support in developing strategies, intervention to move patient through the continuum of care. F/u any delays and help expedite diagnostic,treatment consults. Make referral to Physician Advisor as needed.
3. Knowledgeable of payor requirements including Federal/State guidelines, policies and and procedures. Provide timely clinical informations to the managed care companies as part of contractual agreements.
Works collaboratively with MD's and managed care companies on concurrent denial issues and coordinates direct communication between MD's.
4. Assess patient's clinical readiness and discuss with team available resources based on patient's clinical needs. Initiate PRI as needed. Collaborate and assist SW in the coordination of discharge plan. Obtain authorization for post acute care needs timely. Maintain easy flow of communication regarding patient's development and progress to all involved in care of patient.
5. Participates in the development and improvement of clinical initiatives focused on reducing LOS, Denials; Readmissions.
Actively involve in daily, weekly rounds and intervene in management of complex cases especially (d/c planning) areas. Knowledgeable in hospital and community resources. Preparedness in taking role of resource person among other disciplines.
6. Maintain effective relationship and positive outlook when interfacing with other departments, interdisciplinary team including managed care companies in effort of achieving optimal outcomes.