Case Manager
2 weeks ago
The position provides comprehensive care coordination for patients as assigned and assesses the patients plan of care. The Case Manager is responsible for Length of Stay management and discharge planning. Develops, implements, monitors and documents the utilization of resources and progress of the patient through their care, advocating and facilitating options and services to meet the patients health care needs. Interacts extensively with the care teams to support the clinical roadmap. The intensity of care coordination provided is situational and appropriate based on patient need and payer requirements. This position works independently, receiving supervision of work activities from the Lead CM team, Supervisor of Case Management and Manager of Case Management and is accountable for the quality of clinical services delivered by both them and community partners and identifies/resolves barriers which may hinder effective patient care.
**Position Duties**:
- Coordination of Care
- Manages a defined service line patient population to achieve optimal discharge and continuity of care outcomes in a manner that promotes sound financial stewardship and patient-family advocacy.
- Establishes estimated Length of Stay via MCG criteria and tools,
- Completes an initial screen of all patients on admission (not to exceed within 24 hours of admission) utilizing MCG criteria to identify needs related to care coordination and/or discharge planning.
- Leveraging MCG and other evidence-based guidelines, coordinates development and implementation of a comprehensive discharge care plan in collaboration with the clinical care team.
- Ensures plan of care is in place with all team members. Proactively collaborates with members of the interdisciplinary clinical care team to define and document a clear and comprehensive treatment plan, including post-discharge needs. Identifies and facilitates resolution of variances in the plan of care that may impact length of stay. Facilitates referrals to other disciplines, and monitors for appropriate follow-up.
- Facilitates and provides on-going communication with patient/family and escalates unresolved barriers to timely discharge to Case Management, Manager or Utilization Management Medical Director, as per department protocols.
- Reviews and analyzes third-party payer denials for in house patients, and communicates to attending physician, Case Management, Manager, Utilization Management Medical Director, and Utilization Management Nurse as per department protocols.
- Cultivates and maintains effective interaction/communication with members of the interdisciplinary care team and proactively engages patient and families in the delivery of care across the continuum of care.
- Reviews the patient daily for appropriate patient status, level of care and goal length of stay per established Case Management daily prioritization protocol, utilizing MCG criteria and communicates goal length of stay to clinical care team, patient and family.
- Keeps patient discharge information current in Case Manager EMR documentation. Assesses each patients status and activities daily as appropriate to patient needs. Ensures timeliness of care and identifies barriers to transition of care or discharge.
- Participates in interdisciplinary rounds and/or service line rounds with clinical care team.
- Regulatory responsibilities
- Reviews the patient daily (Observation and Inpatient) for appropriate status and meeting admission or discharge criteria.
- Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct ongoing care planning and discharge planning.
- Utilizes MCG guidelines/pathways to determine admission status, level of care, goal length of stay and continued provision of services as evidenced by audit of documentation in EMR.
- Documents avoidable days, extended length of stay, authorizations and denials for medical necessity in SCM and SAM as evidenced by audit.
- Communicates to Utilization Management Nurse data supporting denial appeals, or notification of potential denials.
- Communicates with payers to resolve potential denials.
- Working knowledge of DRG payment methodology and ICD-9/10 coding system.
- Provides Medicare/Tricare Rights and Detailed Notice of Discharge to patient and families.
- Transition and Discharge Planning
- Assures thorough, early and ongoing transition/discharge plans by collaborating with patients, families, payers and providers across the continuum of care.
- Assesses patient for appropriate discharge placement. Identifies presumed discharge location on admission.
- Consults with social services and other resources as needs or problems are identified.
- Communicates transition/discharge plans and problems to other case managers as care is transitioned. Ensures that health care team is proactive in making arrangements for transition/discharge, and ensures that each transition/discharge plan has clear goals that are attainable. Ensures that
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