Rn Care Manager Inpatient Full Time
1 week ago
The Case Manager I is accountable for a designated patient caseload and plans effectively to meet patient needs, manage the length of stay, and promote efficient utilization of resources.
Specific functions within this role include:
- Facilitation of precertification and payor authorization processes
- 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
- Application of process improvement methodologies in evaluating outcomes of care
- Coordinating communication with physicians.
The role reflects appropriate knowledge of RN scope of practice, current state requirements, CMS Conditions of Participation, EMTALA, The Patient Bill of Rights, AB1203 and other Federal or State regulatory agency requirements specific to Utilization Review and Discharge Planning.
The Care Manager partners with the medical staff, utilizes scientific evidence for best practices, and relevant data to manage the care of the patient over the continuum of their hospitalization.
These activities include admission, continued, extended and discharge reviews in all reimbursement categories to determine medical necessity, assure high quality of care and efficient utilization of available healthcare resources, facilities and services.
This position requires the full understanding and active participation in fulfilling the Mission of Martin Luther King, Jr. Community Hospital. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support Martin Luther King, Jr. Community Hospital's strategic plan and the goals and direction of the quality and performance improvement process activities.ESSENTIAL DUTIES AND RESPONSIBILITIES
Assessment:
- Completes a comprehensive assessment to identify opportunities for intervention that are appropriate and realistic for the patient/family's psychosocial, cultural, spiritual, and physical plan of care.
- Assess the patient's healthcare needs and goals; specifically targeting the physical, functional, psychosocial, environmental and financial status.
- Completes and documents timely clinical reviews based on assessment of medical necessity and documented clinical findings in accordance with Hospital policy and payer requirements.
- Communicates with attending physician regarding appropriateness of patient admissions, resource utilization, and when documentation does not support continued stay.
- Assesses readmission risk based on established Hospital criteria.
Planning:
- Demonstrates an understanding of medical necessity and intensity of service, and incorporates payer requirements into the development of a safe, effective, and timely discharge plan.
- Demonstrates an understanding of the patient's clinical condition, social, and financial resources to determine the most appropriate care setting, practice standards for evaluation, treatment delivery options (Home, SAR, SNF, LTACH, Acute Rehabilitation, Assisted Living, Board/Care, Recuperative Care, Shelter), and resources required to support safe transition of care.
- Incorporates risk of readmission and socioeconomic factors in the creation of a safe and individualized transition plan.
- Engages the patient and family/support network in developing the transition plan.
- Collaborates actively with the interdisciplinary team throughout the patient's stay to reassess and adjust the plan for care progression and transition according to the patient's clinical condition.
- Advocates for the patient with the payer and/or IPA to ensure the most effective care progression and transition plan for the patient.
Implementation:
- Coordinates the progression of care to ensure that the ongoing needs of the patient and family are adequately addressed.
- Identifies psychosocial and financial barriers, (e.g. substance abuse, homelessness, unsafe or abusive living arrangement) and collaborates with or delegates to Clinical Social Work colleagues.
- Identifies discharge planning needs and facilitates transfers to acute and postacute venues.
- Demonstrates working knowledge of the clinical requirements, individual payer networks and coverage, and impact of patient's living environment and support network in creating a transition plan.
- Identifies and facilitates home care and durable medical equipment needs at the time of discharge.
- Facilitates palliative or hospice care when needed
- Works collaboratively and maintains active c
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