Case Management Manager

2 weeks ago

Boulder City, United States Boulder City Hospital Full time

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GENERAL PURPOSE:

Effectively performs Case Management and Utilization Review functions and assists with hospital-wide Quality Improvement Monitoring and Infection Control as needed.

ESSENTIAL FUNCTIONS:

Primary responsibilities of the Case Management/Utilization Review RN include case management, discharge planning, social services and utilization management of patients to ensure they receive quality, medically appropriate care in the most appropriate setting. Able to lift, walk, carry and stand.

DUTIES AND RESPONSIBILITIES:

1. Performs patient assessments of all major domains (physical, functional, financial, and psychosocial).

2. Assists the care team in developing individualized care plans that involve provider and patient choices and goals for care to include assessment, planning and implementing care strategies that are directed toward the most appropriate, least restrictive level of care, that includes acute care and post hospital care.

3. Implements care plans involving health care resources across the continuum.

4. Monitors and evaluates care plan to ensure quality health outcomes are achieved, including education of patients/families on how to follow their post hospital plans of care.

5. Utilize both hospital and community based resources to establish a safe and effective case management plan for patients.

6. Communicate with all stakeholders the required health related information to ensure quality coordinated care and services are provided expeditiously to patients.

7. Advocate for patients and families as needed to ensure that the patient’s needs and choices are fully represented and supported by the health care team.

8. Utilize approved clinical criteria (Interqual, Milliman, etc.) to assess and determine appropriate level of care for patients and to provide clinical information to Medicare, Medicaid and private health plans as requested on an ongoing basis.

9. Understand insurance products, benefits, coverage limitations, insurance and governmental regulations as it applies to the patients health plan.

10. Educating patients/families on their benefits and limitations of their Medicare, Medicaid or private health care coverage

11. Be accountable for understanding role and how it affects utilization management benchmarks and quality outcomes.

12. Continues self-education by reviewing current literature, attending workshops, seminars and formal courses relating to Case Management and Utilization Review.

13. Assists in the maintenance of records and resources for Case Management.

14. Keep Case Management Manager informed of departmental activities, needs and problems.

15. Maintain close liaison with other hospital departments to assure coordination, standardization and continuity of patient care.

16. Perform community outreach education as needed.

17. Participate in hospital-wide Quality Improvement and Infection Control activities as needed.

18. May be asked to provide direct patient care, such as bathing, dressing, and feeding patients, along with assisting in examinations and treatments in extreme or crisis situations.

SKILLS AND ABILITIES REQUIRED:

1. Ability to pass high efficiency respiratory fit test and use program as required by OSHA, Vol. 58, No. 195.

2. Ability to effectively communicate orally and in writing.

3. Must be able to work independently with minimal supervision showing initiative and being a self-starter.

4. Ability to work effectively with all hospital staff to ensure a spirit of harmony, cooperation and excellence in patient care and satisfaction.

EDUCATION AND EXPERIENCE REQUIRED:

1. Graduate from an accredited School of Nursing.

2. Current Nevada State RN Licensure or eligible for licensure.

3. Preferable professional organization membership on a state or national level pertaining to Case Management/Utilization Review.

4. Minimum 3 years Case Management/Utilization Review experience.

5. Knowledge and/or experience with Interqual or similar criteria software.

6. Knowledge of computers, including WORD, EXCEL and EHR

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