Case Manager

Basic Function: 1.

To be responsible for the comprehensive integration of Discharge Planning, Performance Improvement and Utilization Review activities at patient, hospital, and system levels.

2.

Efficiently and effectively ensures the anticipation, identification, and resolution of issues through pre-admission, admission, concurrent and post discharge medical record review 3.

Services as a consultant, provides guidance to the healthcare team on patients in need of transfers, medical review or care plans 4.

Ensures that the patients and families are discharged at the highest level of functioning feasible.

Work with patients, families, internal departments, and external agencies to provide smooth, timely transition of care across the continuum 5.

Activities will be documented as per policy. Information will be analyzed, tracked, trended, and shared with the appropriate medical dental staff or hospital department as needed. Ensures that outcome management (data collection through analysis) information is accurate, communicated, and evaluated for process improvement potential.

Education and Experience

Requirements:

Education:
RN is mandatory. A Bachelors of Science in Nursing from an approved school of Nursing preferred. Currently licensed to practice as a RN in New York State.

Experience:
Previous Utilization Review, Quality Assessment, Discharge Planning or Home Care experience is highly preferred.

Requirements:

• Adheres to the Case Management Philosophy and practices of the UR/QA DP and SW policies and procedures. By following all department policies/procedures, attends all required in-service/meetings. Acts as a role model for high standards of performance.

Works closely with all of the following:

Medical Staff Department, Nursing, Ancillary Services, External, and Internal customers to facilitate high quality intervention, communication and customer satisfaction.

Uses appropriate judgment and lines of authority to maintain the confidentiality and conflict of interest protocols of peer review. Provides guidance, support, and an environment that enables staff and customers to adhere to their responsibilities. Understands and adjusts policies to specific age-related needs of patients. Provides input in ongoing evaluation of policies as processes, regulations, change, etc.

• Screens and assesses high risk patients for potential discharge planning needs using age-appropriate criteria. Communicates with out-patient areas as needed to ensure screening and identification of patients in need of post hospital care planning. Prepforms assessments throughout continuum on all patients over 70 or all patients over 65 who live alone as well as patients with chronic medical problems, readmission or non-compliance issues, temporary or permanent medical treatment or needs, or per pathway protocol. Responds to nursing, physician, ancillary, community, patient and family requests, or indication for assessment. Provides Community Service packets to all patients and families assessed. Documents thoroughly and accurately in chart and Patient Discharge instruction Sheet. Aggregates patient population needs for process/programmatic changes. Acts as RN mentor for educational development.
• Develops Comprehensive Discharge Plan. Initiates/follows comprehensive assessment of patients in need of post hospital services by ensuring medical, functional, psycho-social needs, and/or developmental are identified and met as feasible. Works with families to provide the necessary level of involvement, anticipatory guidance, and support. Works with external agencies to ensure that the appropriate services are available for a timely, smooth transition home, and to ensure the continuity of care. Documents thoroughly on the red bordered sheets. Ensures that discharge planning plays a key role in the internal efficiency of the hospital by timely intervention for a low LOS (i.e. anticipates/identifies and resolves barriers to discharge, as feasible and/or identifies and verifies payment source for services and equipment prior to implementation of discharge plan). Maintains communication with social work regarding all potential ALC patients, prior to actual ALC date. Aggregates patient population needs and facilitates program development (internal and external) to meet challenges of care needs.
• Implements and evaluates the discharge plan. Communicates finalized individual post-hospital care plan. Plans with external agencies to ensure the appropriate services are available and the agencies are able to provide/ensure required post hospital care and long term planning.

Completes written and verbal information including, but not limited to:

patient discharge instruction sheet, HRM – work sheet, final post hospital care plan, required verbal referrals, and required written referrals.

Evaluates the effectiveness of the plan as feasible. Is familiar with outcomes of agencies for information to families if they request such data.

• Ensures that all in-patient care is medically necessary and at the appropriate level. Does pre-admission evaluation in the ED, PAT, and out-patient areas as assigned. Does admission review on first working day post admission with communication to insurance as needed. Does concurrent review on criteria and nursing judgment. Make all contact with insurance companies timely. Assigns LOS by DRG, physician, and medical record documentation and nursing judgment. Appropriately anticipates, identifies, and communicates when a patient can receive services at another level of care, including making the appropriate insurance determination. Issues appropriate, accurate HINN in a timely manner, ensuring patient rights. Anticipates and identifies barriers to an appropriate LOS, and resolve concurrently as feasible. Anticipates UR/QA/DP issues and opportunities and communicates with the attending, consultants, and the clinical department timely. Accurately documents UR activity on Case Management Worksheets. Adheres to observation unit policies.

Consultant to MC, office staff, and healthcare team regarding:
acute care needs, appropriateness, right resources, right setting, etc. Appropriately arranges transfers. Understands the needs over continuum to plan best management plan.

• Ensures effective concurrent Quality Assurance. Works closely with chiefs/QA process, support staff to ensure comprehensive departmental QA plans and assist with annual review analysis. Applies concurrent criteria and ensures that all indicators are prepared for review, brought to department meetings, addressed through recommendations, coordinated as appropriate and documented through the minutes process aggregated for trend. Assists medical staff in the development and continued improvement of their peer review indicators and activities. Document clearly and succinctly all quality assurance variances on worksheets (NYPORTS, ADR's). Anticipates and resolves concurrent issues prospectively as feasible. Identifies trends, patterns or variables, as well as opportunities for focused studies, etc. Responsible for pathway data, management, coordination, and communication. Responsible for quality management data, concurrent collection and intervention with departments. Develops, completes, and analyzes focus projects research (sampling method, hypothesis development, and prioritizing purpose). Timely and comprehensive completion of plans of care and quarterly reports. Facilitates and develops protocols, programs, and processes changes. Familiar and adept with CQI techniques. Familiar and adept with benchmark and outcome data. Participates in credentialing data and system.
• Ensures the comprehensive integration of Utilization Review, Quality Assurance, and Discharge Planning Activity

Recognizes the relationship between:
Quality Assurance, Cost-effective care, Discharge Planning, Customer Satisfaction, Public Relations, Education and Staff Development, and Medical Education. Works on Quality Improvement teams, projects, and programs which assist in continued improvement and self-development. Looks for opportunities to continuously improve the systems in which we work.

• Serves as nurse consultant for Social Worker cases with Clinical or discharge planning needs. Provides home care referrals on Adult Home patients, etc. Assists with or coordinates Nursing Home returns as needed. Coordinates acute hospital to hospital transfers to ensure compliance with all the discharge planning regulations and transfer policy. Provides guidance, support, and back-up to social workers on patients in need of transfer, medical review and care planning.
• Maintains Professional Standards. Attends necessary in-services; seeks learning experiences and gathers medical/community knowledge as needed. Completes hospital wide mandatory in-service program. Maintains and follows universal precautions as indicated. Meets OSHA requirements regarding exposure control and Hep B vaccine Seeks to understand all processes and identifies opportunities for enhancements, seeks education and in-service as needed. Communicates clearly, provides feedback and listens effectively; enables and builds bridges to ensure job and customer satisfaction; has general willingness to see all sides objectively. Exhibits good stress tolerance; creates favorable working environment and customer satisfaction. Obtains cross training on-call, weekend coverage, as well as job performance standards. Provides internal coverage and support to fellow team members to ensure the maintenance of the department's high standards of care. Familiarizes self with and complies with all department and hospital wide policy and procedures.

Salary Range:
$33.71-$50.56 Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.

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