RN Case Manager
Job ID: 12828
Schedule Type: Full Time with Benefits
Weekend Work: Weekends as Needed
Holidays: As Needed
Department Name: Case Management
On Call: No On-Call Required
More information about this job:
Job Summary and Responsibilities:
The individual in this position bears overall responsibility for coordinating patient care activities to ensure that care meets evidence-based practice standards, and regulatory/payer requirements. The role integrates and coordinates utilization management, care coordination, and discharge planning functions. RN Case Managers may work in units such as ETD, Observation, PACU or in any other area of HackensackUMC as deemed appropriate by the leadership of the department. Shift and weekend rotation as needed. The RN Case Manager is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include:
1. Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement
2. Application of process improvement methodologies in evaluating outcomes of care
3. Coordination of communication with physicians, nursing, and staff of ancillary departments
4. Evaluation of care provided against the Length of Stay
5. Collaboration with Admitting to ensure accuracy of patient demographic and insurance information
6. Communication with patients and their families around medical plan of care and discharge plan
7. Assessment and plan for discharge needs and arrangements, including leading multi-disciplinary care conferences and morning 'flash meetings' in conjunction with Nursing.
8. Coordinates/facilitates patient care progression throughout the continuum.
a. Works collaboratively and maintains active communication with physicians, nursing, and other members of the multidisciplinary care team to effect timely and appropriate patient management. b. Identifies and resolves delays and obstacles to discharge in a proactive manner. Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. c. Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge. d. Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues. e. Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated caseload; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis:
i) Communication of all elements critical to the plan of care to the patient/family and members of the health care team.
ii) Completion and reporting of diagnostic testing.
iii) Completion of treatment plan and discharge plan.
iv) Modification of plan of care, as necessary, to meet the ongoing needs of the patient
v) Communication to third-party payers and other relevant information to the care team
vi) Assignment of appropriate levels of care
vii) Completion of all required documentation in the IT Case Management screens, and patient records
9. Completes utilization management for assigned patients. a. Applies approved InterQual criteria as a guideline to monitor appropriateness of admissions and continued stays and documents findings based on department standards. b. Identifies at-risk populations using approved screening tool and follows established reporting procedures. c. Monitors length of stay (LOS) and clinical resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas. d. Refers cases and issues to physician advisor in compliance with department procedures and follows up as indicated. e. Communicates with financial counselors to facilitate covered day reimbursement certification for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed. f. Monitors utilization of resources and reports to Manager. Captures and documents Avoidable Days in Case Management IT system. g. Issues Notices of Non-coverage per hospital policy. h. Provides Part B coverage notification for Observation patients. i. Uphold compliance of regulatory standards for Observation patients including CMS requirement for Code 44.
10. Manages all aspects of discharge planning for assigned patients. a. Meets directly with patient/family to assess needs and develop an individualized plan in collaboration with the physician. b. Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation. c. Ensures/maintains plan consensus from patient/family, physician, and payer. d. Refers appropriate cases for social work intervention based on department criteria. e. Collaborates/communicates with external case managers. f. Initiates and facilitates referrals to the Social Worker as defined in department policy. g. Documents relevant discharge planning information in the System Case Management. IT system according to department standards. h. Facilitates transfers to other facilities. i. Follows ED Case Manager Job Description and Performance measures when assigned to ED.
11. Finance a. Monitors bed availability on assigned unit in conjunction with nurse manager. b. Communicates OBSERVATION LOS to patient and family. Has patient/significant other sign Acknowledgement Form as to status and tentative discharge date and time. c. Initiates calls/communication to managed care companies, on all patients as required. d. Assist in calling for hospital test results in absence of timely reporting to help expedite patient movement. e. Solicits 'Patient Choice' for support services post discharge and confirms in EPIC. f. Monitors appropriateness of resource consumption including orders for CT and MRI. Refers variances to Physician Advisor. g. Knowledgeable about Indigent Medication Programs. Updates and posts list in Physician Lounge areas for physicians and hospitalists. h. Works in coordination with Registration to reduce number of clerical errors in patient status. Makes sure patient insurance correct as well as status. Notifies Registration of changes needed to produce accurate Face Sheet revisions. i. Refer appropriate patients to Financial Counselor. j. Calls insurance company for pre-approval of high cost testing when required. k. Applies Case Management Protocols as applicable.
12. Quality-Actively participates in clinical performance improvement activities by: a. Assisting in the collection and reporting of indicators tracking efficiency of case management processes. b. Use of data to drive decisions and plan/implement performance improvement strategies related for assigned patients, including fiscal, clinical, and patient satisfaction data. c. Collection of delays in service data and data for specific performance and/or outcome indicators as determined by the director. d. Solicits Physicians/Hospitalist in needs related to Case Management activities. e. Attends in-service programs relative to scope of care relative to management of chronic health conditions causing readmissions such as Heart Disease, Cancer, Respiratory Conditions, Arthritis, Hypertension, Diabetes or Depression. f. In the process of chart review screens orders and entries for appropriate signing, pended orders and dating as required by The Joint Commission/CMS. (CPOE)written. g. Practices hospital service initiatives to improve HCAPPS scores. h. Arrange home medications for patients to avoid unnecessary admissions. i. Makes timely referrals to discharge entities as required. Makes referrals to Social Worker as outlined in policy.
13. Service a. Calls and communicates with major payors to discuss pitfalls and problem cases and documents interventions in Case Management IT system. b. Attends unit and committee meetings as required. c. Prioritizes expedition of Observation patients on units. d. Provides relief coverage update on patient caseload and concerns. e. Coordinates 'end of life' discussions with physicians related to patient needs, if indicated. f. Calls and arranges transportation arrangements for patients on discharge. g. Assists in notification of bed availability and readiness on respective unit and communicates to appropriate personnel. h. Notifies patient of hospital discharge time and documents date and time of patient agreement on whiteboard in patient room. i. Confirms with attending physician consultants have signed off case.
14. Growth a. Uses Interqual Guidelines as a coaching tool to aid physicians /hospitalists in appropriate placement of patients. Consults with Physician Advisor as appropriate.
15. Adheres to the Medical Center's Organizational Competencies and the Standards of Behavior.
Knowledge, Skills and Abilities Required:
1. Case Manager, Registered Nurse Graduate of a NLN/AACN accredited program in nursing a plus.
2. Bachelor's degree in nursing (BSN) or 1 year experience for non BSN HackensackUMC employees.
3. Excellent interpersonal communication and negotiation skills.
4. Strong analytical, data management and PC skills.
5. Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
6. Understanding of pre-acute and post-acute venues of care and post-acute community resources.
7. Strong organizational and time management skills, as evidenced by a capacity to prioritize multiple tasks and role components.
8. Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.
9. Committed to scheduled weekend rotation to meet department needs.
10. Commitment to rotate to evenings as required.
11. Current and valid NJ State Professional Registered Nurse license.
12. Maintains American Heart Association Basic Life Support HCP certification.
Knowledge, Skills and Abilities Preferred:
1. Case Management certification.
2. R.N. with at least 2 years clinical experience in the relevant clinical specialty (e.g., care managers for pediatric patients should have pediatric nursing experience) with a minimum of 2 of the 2 years in Case Management in an acute care setting.