Case Manager Nurse
1 month ago
This position comprehensively plans for targeted patient populations. Performs resource management, including denial management, utilization management, access to the appropriate level of care, discharge planning, care facilitation, and referral to other levels of care. Works collaboratively with the multidisciplinary care team to facilitate achievement of desired treatment outcomes.
MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Current West Virginia licensure as a Registered Professional Nurse or licensure as Registered Professional Nurse in another state with a temporary West Virginia practice permit.
EXPERIENCE:
1. Five (5) years clinical experience.
PREFERRED QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
1. Bachelor's degree in Nursing (BSN)
CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
1. Manages all aspects of transition/discharge planning for assigned patients in a timely manner.
2. Collaborates with all members of the multidisciplinary team to facilitate the transition/discharge process for designated caseload.
3. Monitors the patient's progress; intervening as necessary and appropriate, to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective.
4. Provides education as needed to staff, physicians, and patients and their families to ensure effective transition planning.
5. Meets directly with the patient and/or family to assess needs and develop an individualized transition/discharge plan in collaboration with the physician team.
6. Communicates with the multidisciplinary team and post-acute providers when applicable, any complex family dynamics that may directly impact patient care and transition/discharge planning.
7. Initiates and facilitates referrals to post-acute services- including but not limited to: Homecare, Durable Medical Equipment, Hospice Care, Long Term Acute Care Facilities, Acute Rehab Facilities, and Skilled Nursing Facilities.
8. Communicates all necessary information regarding transition/discharge plan to the multidisciplinary team, patient and family.
9. Provides timely and comprehensive documentation of interactions with patient and/or families and all transition/discharge planning activities and progress according to departmental policy.
11. Assists patient/families with completion of medical power of attorney, health care surrogate, and advanced directives
12. Collaborates for appropriate resource and financial management which may include but is not limited to: financial assistance coordination/referrals, entitlement program coordination/referrals, or patient benefit coordination
13. Utilizes quality screens in the electronic record to identify potential issues including but not limited to- avoidable delays and readmissions.
14. Completes clinical reviews for patients.
15. Applies approved utilization criteria to ensure medical necessity of patient's admissions and continued stays, and documents the findings based on department standards, policy and procedure.
16. Screens for appropriate authorization and level of care.
17. Facilitates covered day reimbursement certification for assigned patients and discusses payor criteria and issues on a case by case basis with clinical staff (ie. Peer to Peer) and follows up to resolve problems with payors as needed.
18. Educates hospital staff and physicians to payer regulations and managed care principals to prevent denials.
19. Fosters the integration of staff and/or students into the healthcare team.
PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. Working closely with others.
2. Working protracted or irregular hours.
3. Working around biohazards.
4. Working around infectious diseases.
5. Working with hands in water.
6. Working with electrical hazards associated with patient care equipment.
SKILLS AND ABILITIES:
1. Knowledge of patient's current medical insurance coverage and limitations and the precertification requirements for Durable Medical Equipment (DME), post-acute placements, infusions, transfers etc
2. Knowledge of relevant scientific principles, established standards of care and/or research findings.
3. Knowledge of procedures and techniques involved in administering routine and special treatments to patients.
4. Knowledge of and appropriate application of the nursing process.
Additional Job Description:
Scheduled Weekly Hours:
40
Shift:
Day (United States of America)
Exempt/Non-Exempt:
United States of America (Exempt)
Company:
THOM Thomas Hospitals
Cost Center:
553 THOM Utilization Review
Address:
4605 Maccorkle Ave SW
South Charleston
West Virginia
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