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Care Management Coordinator

3 months ago

Madison, United States Boone Memorial Hospital Full time
Job Details

Job Location
Main Hospital Campus Headquarters - Madison, WV

Description

This position will serve as a care coordinator among healthcare providers, patient's and their families. The Case Manager oversees all aspects of a patient's admission and discharge. Coordinates and conducts initial, concurrent, and retrospective medical record reviews. Makes utilization decisions based on InterQual/MCG criteria. Collaborates and communicates with other internal and external professionals to ensure appropriate and timely discharge planning consistent with the patients continued need for inpatient care.

Case Management does both utilization review and discharge planning. The utilization review nurse involves making sure that a patient is getting care that's medical necessary and getting it in the correct setting. Discharge planning is the process of predicting the patient's continuing medical needs after they leave the hospital and putting in place a plan to meet those needs. This may include negotiation with the pharmacy, home healthcare company, health insurer, and patient.

One of the key roles of the hospital case manager is to assess the patient's health insurance plan and work with the revenue cycle team to ensure that the best care is delivered with the least financial burden. They would also make sure that the revenue cycle has all the information available that the insurer needs to approve payment for the hospitalization and works to prevent insurance claim denials.

Essential Functions

Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.
  • Coordinates/facilitates patient progression throughout the continuum:
  • Addresses/resolves system problems impeding diagnostic or treatment progress; proactively identifies and resolves delays and obstacles to discharge
  • Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge
  • Perform Utilization Management, and Quality Screening for assigned patients
  • Applies approved utilization acuity criteria to monitor appropriateness of admissions and continued stays, and documents findings based on department standards
  • Utilizes InterQual/MCG criteria to ensure appropriate level of care
  • Communicates utilization findings and patient specific case management issues to Revenue Cycle Team
  • Identifies at-risk populations using approved screening tool and follows established reporting procedures
  • Monitors length of stay (LOS) and ancillary resource use on an ongoing basis and takes action to achieve continuous improvement in both areas
  • Communicates with Patient Accounts about reimbursement certification for assigned patients and discusses payor criteria and manages all aspects of discharge planning for assigned patients; queries and schedules discharge planning meetings with swing bed patients and their representatives
  • Meets directly with patient/family to assess needs and develop an individualized discharge plan in collaboration with physician.
  • Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation
  • Documents relevant discharge planning information in the medical record according to Department standards
  • Actively participates in clinical performance improvement activities
  • Uses data and reports hospital and quality measure criteria
  • Collects delay and other data for specific performance and/or outcome indicators as determined for Critical Access Status and/or Quality indicators required for CAH.
  • Participates in development, implementation, evaluation and compliance of swing bed criteria for hospital
  • Facilitates and promotes swing bed admissions both internally and externally
  • Performs chart abstraction and facilitates chart review for CAH compliance
  • Exceptional interpersonal skills with excellent written and verbal skills
  • Other duties as assigned
Required Skills, Qualifications, and Competencies
  • Knowledge of CMS Conditions of Participation Guidelines for Discharge Planning, Utilization Review, Documentation, Medicare Important Message, Face to Face Requirements, and Patient Choice
  • Knowledge of Medicare, Medicaid, and Managed Care Products and the requirements of each payer to meet the various levels of care for post-hospital services
  • Knowledge of CMS guidelines and use of level of care determination for inpatient and observation, CMS inpatient only list and other payer guidelines as required
  • Knowledge of nursing, standards based practice, shared governance, organizational initiatives, in terms of theories and practices to serve as a resource and educator to others
  • Knowledgeable regarding InterQual/MCG criteria for utilization review; strong knowledge of InterQual/MCG Level of Care criteria
  • Advanced knowledge of utilization management principles, concepts, and strategies including admissions criteria, levels of care, and denials
  • Advanced knowledge of commercial insurances, Medicare, Medicaid, and State/Federal regulations which impact utilization management
  • Strong organizational skills
  • Effective leadership skills
  • Effective written and verbal communication skills
Supervisory Responsibilities
  • None
Physical demands
  • Ability to see and hear within normal ranges with or without aid.
  • Ability to bend and move within normal ranges.
  • Ability to be stationary for long periods of time.
  • Finger and hand dexterity.
  • Ability to lift a minimum of 10-20 lbs.
Travel required
  • None
Required education and experience
  • Must maintain and possess a current license as a Registered Nurse (RN) or Licensed Practical Nurse (LPN)
  • Reports to CNO
  • 2-4 yrs of related experience preferred.
Preferred education and experience
  • BSN and CCM Certification preferred.


Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of all activities, duties, or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time.

Equal Employment Opportunity Policy Statement

Boone Memorial Hospital, Inc. provides equal employment opportunities to all personnel and applicants for employment and prohibits discrimination, harassment, prejudice, or behavior of any type based on race, color, religion, age, sex (including pregnancy), national origin, disability status, family medical history or genetic information, past or present military service, sexual orientation, gender identity or expression, family or parental status, political affiliation, or any other characteristic protected by federal, state or local laws.