RN/Case Manager

RN/Case Manager (FT)

POSITION SUMMARY

• Responsible for coordinating clinically complex patients’ care across a continuum; ensuring and facilitating the achievement of quality clinical and cost outcomes; negotiating, procuring and coordinating appropriate services and resources needed by the patients; and at key points, intervening to address and resolve issues/concerns.

QUALIFICATIONS

1. Knowledge, Skills and Abilities
   • Excellent customer service skills.
   • Reads and understands the English language.
   • Ability to think critically and analytically with little or no supervision
   • Ability to work effectively in situations of high stress and conflict and communicate goals and outcomes.
   • Ability to process information and prioritize
   • Possesses exceptional verbal and written communication skills
   • Possesses independent work habits, is self-reliant and self-directed
   • Ability to learn, adapt, and change as required by the job functions
   • Ability to maintain absolute confidentiality of material and information accessed and reviewed
   • Basic computer literacy
   • Ability to move freely, reach, bend, and complete light lifting
   • Ability to use good body mechanics while performing daily job functions and ability to follow specific OSHA guidelines
   • Ability to maintain attendance to meet standard job practices

1. Education
   • License LPN or Registered Nurse
   • Case management or UR certification is preferred
2. Licensure
   • Licensed in good standing with the Georgia Board of Nursing
3. Experience
   • Minimum 3 years relevant clinical experience required.
   • 3-5 years of discharge planning experience
4. Interpersonal skills

1. Essential technical/motor skills
2. Essential physical requirements
   • Sedentary: Exert up to 10 lb. of force occasionally and/or a minute amount frequently - greater than 75%

1. Essential mental requirements

1. Essential sensory requirements
2. Other
3. Equipment used

OTHER QUALIFICATIONS

1. Exposure to hazards (body fluid exposure level)
   • Level II

1. Age of Patient Populations Served
   • Neonates 1 - 30 days
   • Infants 30 days - 1 year
   • Children 1 - 12 years
   • Adolescents 13 - 18 years
   • Adults 19 - 70 years
   • Geriatrics - 70+ years

STANDARDS OF PERFORMANCE

• CRMC employees are devoted to serving our customers – including patients, physicians, fellow-employees and our community by adhering to the Standards of Performance. We are here to make all of our customers feel special.

1. Respectful and Confidential – Employee respects the rights of privacy of our patients. Ensures cultural differences are respected.score: N/A
2. Responsive – Employee responds quickly, graciously and appropriately to customer needs. Employee thanks customers.
3. Gratitude and Attitude – Employee’s behavior shows that he/she believes that each of us controls our own attitude and that what is important is not so much as what happens to us, but how we choose to react to it.
4. Pride, Ownership, and Image – Employee accepts all the rights and responsibilities of being a part of the CRMC family.
5. Communication – Employee is personally accountable for positive communication with the customer – patients, family members and co-workers.
6. Teamwork - Employee contributes positively to the CRMC team and is committed to treating coworkers with courtesy, honesty and respect. Employee abides by the Time and Attendance Policy. Employee has team pride in the purpose of our work – saving lives.

JOB SPECIFIC DUTIES AND PERFORMANCE STANDARDS

• Below are those tasks, duties, and responsibilities that comprise the means of accomplishing the position’s purpose and objectives. These are critical or fundamental to the performance of the position. They are the major functions for which the person in the position is held accountable. Following are the essential functions of the position, along with the corresponding performance standards.
  • Care Facilitation
    • Assesses patients’ clinical level of care needs to assure that the patient is receiving the right care, at the right time, by the right team, in the right location, to improve outcomes and ensure optimum utilization of resources.
    • Documentation of all interventions per hospital/departmental policies
    • Provides recommendations for appropriate clinical interventions working collaboratively with all health care team members
    • Provides referrals as indicated to the appropriate health care team member and/ or post-acute service.
    • Timely identification of patient problems and barriers to care, which allows for proactive management.
    • Actively identifies and proposes resolutions to clinical and/or operational bottlenecks that impede progression of care.
    • Provides consultation and mediation services to facilitate progression according to plan of care
    • Provides recommendations for appropriate clinical interventions working collaboratively with all health care team members.
• 
  
  • • • Need for discharge planning assessment
      • Need for social worker intervention
      • Need for external case management intervention
  • Education
    • Actively influences physician practice patterns to optimize patient outcomes
    • Reinforces and ensures appropriate patient education is carried out according to plan across the continuum
    • Provides ongoing educational opportunities to enhance health care team's knowledge of case management services
    • Participates in and facilitates patient/family education and communication
  • Utilization Review
    • Identifies need for physician advisor intervention and facilitates same
    • Completes Hospital Issued Notice of Noncoverage (HINN) processes
    • Maintains documentation of non-commercial utilization review function per hospital policy and federal and state requirements
    • Utilizing established criteria reviews and interprets both clinical and financial data relevant to assigned population and/or area.
      • Completes admission reviews within 24 hours or first business day following admission
      • Daily review of medical necessity for all inpatients
      • Performs concurrent and discharge reviews on inpatients and provides to insurance provider(s) as required
      • Completes admission and concurrent stay documentation per utilization management plan
      • Completes verification of patient benefits when required
      • Completes verification and correction of patient status when necessary
      • Monitors outpatients and outpatients receiving observation services per hospital policy
    • Obtains authorization number for new admissions and documents number of days approved, next review date and level of care in the department utilization review documentation tool
    • Obtains applicable contact information (e.g. name, number) from providers as required for follow-up
    • Facilitates expedited appeals to appropriate physicians for completion
    • Forwards insurance denials to appropriate entities for follow-up and appeal activities
  • Data Collection and Process Improvement
    • Participates in identifying clinical practice variances and providing variance analysis.
      • 31 day readmissions
    • Accurately records all delays in patient care progression according to hospital/departmental policy
    • Assists with appropriate compliance with regulatory requirements, both state and federal
      • Quality and risk reporting
    • Facilitates the development of case management performance improvement action plans and monitor effectiveness.
    • Participates in monitoring practice patterns and intervenes to affect change in practice.
      • Compliance with selected diagnosis standard of care (Core Measures)
  • Leadership
    • Serves as an expert resource regarding reimbursement and clinical practice issues
    • Serve as a coach, mentor and role model to all professional staff
    • Communicates confidently and effectively with all levels of hospital staff, physicians and payors
    • Is assertive without being overly aggressive
    • Conveys an impression which reflects favorably upon the public relations of the organization
    • Performs other duties and responsibilities as assigned
  • Common Responsibilities
    • Data entry is timely and accurate
    • Answers phones timely and appropriately
    • Familiar with office equipment
    • Takes messages and relays it to the appropriate person
    • Reviews and understands instructions given in the communication book and department meetings
    • Attend department meetings and in-services
    • Current licensure is maintained and renewed in a timely manner
    • Maintains current certification and/or training in safety and ethics programs
    • Assesses and provides for communication needs of patients or customers who are not proficient in English, or who are deaf, or blind
    • Assesses and provides for special needs of patients or customers who are disabled
  • Professional Behaviors/ Responsibilities
    • Adheres to department and Hospital decorum
    • Maintains professional and neat appearance with regular hygienic habits to prevent workplace offensiveness
    • Maintains familiarity with and practices:
      • All hospital and department specific policies and procedures (i.e., safety, fire, hazardous materials)
      • Demonstrates compliance with the company's ethics program
      • Team building skills
      • Conflict resolution skills
      • Hospital values
      • Hospital goals

REGULATORY COMPLIANCE

• Below are any additional competencies as related to regulatory compliance that are specific to the job title and not listed in the other sections of the document.

EDUCATION AND COMPETENCY

• Attends all mandatory and department-specific education and training programs as required.
• 
  Attends all required education and training and can describe his/her responsibilities related to department safety and specific job related hazards.
• 
  Has met all required competencies for the evaluation period as evidenced by job specific competency evaluations.