Case Manager, Per Diem

I.               PURPOSE & PRIMARY FUNCTIONS

           Definition: The Case Management Society of America (CMSA) defines Case
   Management as a "collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual's and family's comprehensive health needs through communication and available resources to promote quality, cost-effective outcomes."

The Nurse Case Manager maintains the responsibilities of Utilization Review and Discharge Planning for all hospital patients under CMS Conditions of Participation Regulations. The Nurse Case Manager is responsible for screening all patients against level of care criteria to qualify the level of care for hospitalization, monitor continued stay and patient response to interventions and the plan of care and develop appropriate discharge plans for all patients who meet high risk screening criteria as well as those who do not if one is requested by the Attending Physician. When the patient is ready for discharge or transfer to the next level of care, it is the Nurse Case Manager who works to develop those plans within the healthcare team and maintains responsibility for the safe communication and implementation of the plan at the time of discharge. The Case Manager must assess every patient against all elements of Federal and State regulations for hospital level of care (a Condition of Participation) and carry out a set of functions that ensure that the hospital stay is appropriate and necessary, and the level of care is correct. The Nurse Case Manager collaborates with nursing/medical staff and other providers to ensure the timely delivery of high-quality care and is delegated to carry out regulatory requirements for the assessment of and communication to the patient by the hospital for all acute inpatient and observation status statutes.

II.              POSITION QUALIFICATIONS

1. Licensure/Certification/ Registration:

• License, Certification, Registration - Nurse Case Manager
• Current Massachusetts R.N. License
• Bachelor’s degree preferred; BSN preferred.
• Certification in Case Management preferred.

1. Education:

• Education and Training - Nurse Case Manager
• Registered nurse from an accredited school of Nursing
• Minimum 7 years demonstrated experience as an RN in the acute hospital and/or home care setting; 2-5 years experience as a Nurse Case Manager preferred.

1. Other Qualifications:

• Proven excellent interpersonal and communication skills
• Ability to maintain confidentiality
• Proven collaboration skills with other disciplines
• Proven ability to work independently
• Proven excellent organizational skills and problem-solving ability
• Demonstrated ability to establish and maintain relationships with physicians and other healthcare professionals
• Computer experience necessary ability to use screening software, internet-based programs and documentation and data systems

• MACHINERY, TOOLS & EQUIPMENT

Normal business equipment including telephone, fax, photocopy machine, answering machine, computer, and printer.

1. WORKING RELATIONSHIPS

·                Reports to:

Case Management Director

·                Works in collaboration with:

Nurses, physicians, other providers, other departments, VNA liaisons and other case managers

• Direct contact with the following age groups:

X

0-11m

X

1-3y

X

3-5y

X

6-11y

X

12-17

X

18-45y

X

45-59y

X

59-79y

X

>80y

_

N/A

This position will have the following access level to patient health information:

No PHI      _

Limited PHI      _

Broad PHI      X

V.             WORKING CONDITIONS

Physical Demands: See attached checklist

VI.            DUTIES & RESPONSIBILITIES

1. Communication and Teamwork: Demonstrates a commitment to maintain effective communications with all health team members and with all Hospital customers to facilitate and promote effective working relationships, customer service and patient satisfaction.

1.1.      Demonstrates professional and courteous behavior to staff, patients and others and introduces self to visitors/patients.  Wears ID badge 100% of time while working.  

1.2.      Communicates information clearly to patients, visitors and co-workers in both verbal and written form and documents information clearly and completely

1.3.      Displays, through conduct and performance, an attitude which reflects the respectful treatment of others, a commitment to teamwork and commitment to the Hospital’s mission, values, and goals.  Participates in all appropriate ways to attend to the needs of all patients and visitors.

• Actively participates in department-specific and/or interdisciplinary performance improvement and able to articulate performance improvement initiatives.

1. Work Practices: Demonstrates a commitment to maintain work practices that comply with established Hospital policy

2.1.      Observes and respects the personal privacy and confidentiality of information regarding patients, visitors, physicians, applicants, and co-workers. Adheres to HIPAA regulations.

2.2.      Maintains regular work attendance and is available for work as scheduled

2.3.      Dresses in a professional, business-like manner, reflecting the Hospital’s dress policy and the need to be responsive to the perceptions of patients and visitors.

2.4.      Attends and completes all mandatory education and information sessions

2.5.      Maintains current certification, licenses, registrations, etc. as required by the position

2.6.      Willingly provides assistance to others when requested and accepts other job-related duties as assigned.

2.7.      Equally shares responsibility for overtime, rotation, etc. and any necessary schedule changes

• Attends departmental staff meetings on a regular basis and takes responsibility for becoming knowledgeable of meeting content if not attended.

1. Safety: Demonstrates a commitment to promote a safe environment for patients, visitors, and peers.

3.1       Utilizes proper body mechanics, universal precautions, etc.  in the work environment

3.2       Remains knowledgeable regarding the utilization of emergency response in fire, code, or disaster situations

• Identifies unsafe conditions in the work environment and takes appropriate actions to reduce/eliminate risk; reports all incidents that put the environment, patients, visitors, or staff at risk.
• Understands importance of patient safety issues and initiates appropriate action to address.

1. Professional Competency: Demonstrates a commitment to maintain competencies and participate in those activities which contribute to the on-going development of self and others.

4.1       Accomplished all goals and objectives identified in prior year’s performance assessment meeting

4.2       Incorporates knowledge regarding the growth, development, physical, emotional, and cultural needs of the populations served.

4.3       Applies all applicable Hospital and departmental standards when planning and providing care or a service.

4.4       Consistently produces high quality work with a minimum of errors.  Maintains a high level of productivity and seeks ways to assist others when/if work is completed.

4.5       Demonstrates autonomy, initiative, professionalism and an ability and willingness to problem-solve.

• Assumes responsibility for own continuing education and learning and suggests to Director/Senior Manager the means to accomplish it.
• Participates, as requested, in orienting and mentoring other staff.

1. Performs integrated and concurrent utilization, quality, and discharge planning reviews of all admissions
   • Accurately certifies admissions and continued stays using Interqual and SI/IS criteria
   • Conducts timely review s of all cases and maintains accurate files
   • Appropriately refers cases (i.e., denials and quality issues) to physician and UR Coordinator
   • Collects and reports data elements and clinical reviews for certification by insurers.

1. Conducts ongoing assessments of each patient’s level of care and collaborates with physician to facilitate appropriate discharge and or transfer.

1. Using defined standards and policies, assesses the patient and family for discharge needs and develops discharge plans based on defined needs
   • Provides family and patient education related to discharge options and resources
   • Appropriately refers to and uses hospital and community resources and services
   • When necessary, uses the appeal process to advocate for the patient.

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