Case Manager
4 weeks ago
Under general supervision of the Director of Case Management, RN Case Manager provides support to the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates and coordinates utilization management, care facilitation and discharge planning functions. 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:
- Facilitates pre-certification and payor authorization processes.
- Facilitates collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement.
- Employs process improvement methodologies in evaluating outcomes of care.
- Supports and coaches clinical documentation efforts and serves as a clinical resource for coders ensuring that documentation accurately reflects severity of illness and intensity of service.
- Coordinates communication with physicians.
- Coordinates and facilitates patient care progression throughout the continuum of care.
- Completes Utilization Management and Quality Screening for assigned patients.
- Applies approved clinical appropriateness criteria to monitor appropriateness of admissions and continued stays, then documents findings based on Department standards.
- Identifies at-risk populations and follows established reporting procedures.
- Monitors LOS and ancillary resource use on an ongoing basis. Takes action to achieve continuous improvement in both areas.
- Refer cases and issues to Care Management Medical Director (CMMD) in compliance with Department procedures and follows up as indicated.
- Communicates with business office and payors to facilitate covered day reimbursement certification for assigned patients. Discusses payor criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed.
- Ensures that all elements critical to the plan of care have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
- Manages all aspects of discharge planning for assigned patients.
- Actively participates in clinical performance improvement activities.
- Assists in the collection and reporting of financial indicators including case mix, LOS, cost per case, avoidable days, resource utilization, readmission rates, denials and appeals.
- Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data.
- Collects, analyzes and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes.
- Documents key clinical path variances and outcomes that relate to areas of direct responsibility (e.g., discharge planning).
- Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.
- Abide by HMH Legal Compliance Code of Conduct.
- Maintains patient confidentiality and appropriate handling of PHI.
- Maintains a safe work environment and reports safety concerns appropriately.
- Performs all other related duties as assigned.
Requirements
Education: Graduate of a school of professional nursing.
Experience: RN with two years of Case Management experience preferred but may consider LVN with Case Management/Coordination of care experience. Knowledge of MCG Guidelines, working with Correctional Care Patients and UTMB Managed Care is a plus.
Licensure/Certification: Current licensure as a Registered Nurse in the state of Texas. Certification with the Fellowship of American Academy of Case Managers (FAACM) preferred.
Required Skills: Must have strong analytical, data management, organizational and time management skills. Performs duties in a manner to promote quality patient care and customer service / satisfaction, while promoting safety, cost efficiency, and a commitment to the CQI process.
Work Schedule: 4 -10hr day/work week
Benefits
- Health Care Plan (Medical, Dental & Vision)
- Retirement Plan (401k, IRA)
- Life Insurance (Basic, Voluntary & AD&D)
- Paid Time Off
- Short Term & Long Term Disability
- Training & Development
- Wellness Resources
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