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Rn Case Manager
3 months ago
At Bon Secours Mercy Health, we are dedicated to continually improving health care quality, safety and cost effectiveness. Our hospitals, care sites and clinicians are recognized for clinical and operational excellence. Primary Function/General Purpose of Position The RN Care Manager is a key contributor to the overall financial, quality, and clinical performance at St. Francis Health System. The RN Care Manager will: Facilitate the extraction of all clinical documentation necessary to qualify a patient for hospital level of care utilizing the information maintained in the electronic medical record (ConnectCare®). Provide a positive financial impact to the institution through interaction with physicians, nursing staff, other patient care givers, and coding professionals to ensure that medical record documentation accurately reflects the level of services rendered to patients and the clinical information utilized in profiling and reporting outcomes is complete. Monitor and evaluate care to ensure costs are medically necessary, provided in the most appropriate setting, and are generated according to governmental and regulatory agency standards. Identification and reporting of potential quality of care issues and reporting of variances through the Quality Improvement Program. Educate all members of the patient care team on documentation guidelines on an ongoing basis. Responsible for the timely coordination of health care services for selected patient populations to meet specific health care needs in a cost-effective manner. Support an outcomes-oriented patient care delivery system, which places the patient at the center of all activities. Coordinate patient education to promote independence and the ability to care for one’s self. Serve as the primary clinical resource to assist the social worker in developing, altering and expanding the discharge plan of care on high-risk patients to encompass multidisciplinary patient care needs. Employment Qualifications Education: Graduate of an NLN accredited school of nursing. Bachelor of Science degree in Nursing (BSN) or currently enrolled in a BSN program. Current, unrestricted license to practice nursing in the State of South Carolina. Five (5) years of recent acute care nursing or four (4) years recent clinical experience, and one year utilization review experience. High level of clinical skills required. Utilization management experience preferred. Familiar with Medicare MS-DRGs and Medicare PPS preferred. Performance Improvement (PI) experience preferred. Clinical leadership experience preferred. Milliman medical review criteria experience preferred. Knowledge of acute care regulatory/accreditation requirements preferred. Excellent computers skills and current knowledge of the electronic medical record. Certified Care Manager (CCM) certification preferred Essential Job Functions Utilize proactive triggers (diagnoses, cost criteria, and complications) to identify potential over/underutilization of services gleaned from all information maintained in the electronic medical record (ConnectCare®). Facilitate transfers/discharges to lower acuity units or settings as appropriate. Demonstrate knowledge of documentation requirements and guidelines in accordance with Medicare and other Regulatory Agencies. Identify the most appropriate principle diagnosis and complications and co-morbid conditions (CC’s) including data to accurately reflect severity of illness in compliance with regulatory agencies. Confer with Clinical Documentation staff face to face or via a question sheet to clarify information, obtain needed documentation to establish severity of illness and intensity of service. Conduct follow-up reviews of medical necessity and update documentation at least every two to three (2-3) business days. All Medicare, Medicaid and indigent Observation patients are reviewed daily and sent to second level review by Physician Adviser. Review clinical issues with the Physician to establish medical necessity for all patients. Participate in ongoing education for staff, including new clinical documentation practices, and the electronic medical record (ConnectCare®). Initiate and upgrade initial clinical review to reflect any changes in the patient status, procedures/treatments, and confer with the physician to identify primary diagnosis. Evaluate Medicare admissions for appropriateness using approved criteria to determine Severity of Illness (SI) and Intensity of Service (IS) and confer with physicians for inappropriate cases or cases that do not meet the approved criteria. Refer all Medicare, Medicaid and Self-pay patients to Physician Adviser for second level review when inpatient status is questionable. Refer all Medicare, Medicaid and Self-pay Observations patients to Physician Adviser daily. Include Quality Assurance in every aspect of Care Management role. Monitor and evaluate the quality of care provided concurrently. Report variances through the Quality Improvement Program. Improve the overall quality and completeness of clinical documentation by performing admission/continued stay review using clinical documentation guidelines. Implement appropriate referrals to Physician Advisor in a timely manner. Prioritize patient care needs based on situational analysis, functional assessment, medical record review, and application of clinical review criteria. Act as the primary clinical resource to assist the social worker in developing and expanding the plan of care to encompass multi-disciplinary patient care needs. Facilitate multi-disciplinary patient care by maintaining rapport and communication with the treatment team to monitor and evaluate the plan of care, identify/prioritize problems and make adjustments made as required. Collaborate with Social Worker, hospital staff and medical staff to direct care towards predictable and fiscally responsible outcomes Maintain relationships and open communication with the patient/family to provide concurrent information regarding diagnostic testing, treatment plans and outcomes. Participate in the development, implementation and evaluation of clinical pathways. Provide/initiate appropriate education to the patient/family and develop new educational resources if gaps exist. Educate hospital and medical staff regarding Care Management, Utilization Review and other current related issues toward the reduction of length-of-stay. Educate internal staff on and changes in clinical documentation expectations or medical necessity/patient status issues. Maintain positive, open communication with physicians, interdisciplinary care team members and department managers and attend all interdisciplinary care rounds on assigned unit(s). Assist the Social Worker where necessary with discharge planning activities all discharge planning notes from are documented in (ConnectCare®) through case management one stop. Utilize Ensocare CareFinder Pro when making referrals to the next level of care when patient is not discharging to home. All care management staff (RN/SW) will be responsible for the following: Initiates and explains Condition Code 44 after discussion with attending physician and virtual UR nurse. Initiates and explains Observation letters on admission and obtains signature for all patients within 24 hours of admission. Initiates and explains Medicare/Medicaid in house denial after collaboration with attending Physician, Care Management and/or Administrator. Skills: Must possess the ability to: Organize information quickly and effectively. Prioritize and complete multiple tasks effectively. Participate in the team as an equal, active member. Remain oriented to customer service at all times. Document completely and accurately in the medical record and in other written forms of communication. Communicate ideas and thoughts efficiently verbally and in written form. Think critically and formulate ideas easily. Adapt to an ever-changing environment. Remain flexible in various situations and problems. Evaluate, assess, and teach. Able to participate collaboratively with all members of care team. Additional skills: Excellent nursing assessment skills. Analytical thinking and problem-solving ability. Good verbal and written communication skills adaptable to individual levels of understanding. Proficiency in Microsoft. Basic knowledge of automated discharge planning via internet products. Many of our opportunities reward* your hard work with: Comprehensive, affordable medical, dental and vision plans Prescription drug coverage Flexible spending accounts Life insurance w/AD&D Employer contributions to retirement savings plan when eligible Paid time off Educational Assistance And much more *Benefits offerings vary according to employment status All applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, sexual orientation, gender identity, age, genetic information, or protected veteran status, and will not be discriminated against on the basis of disability. If you'd like to view a copy of the affirmative action plan or policy statement for Mercy Health – Youngstown, Ohio or Bon Secours – Franklin, Virginia; Petersburg, Virginia; and Emporia, Virginia, which are Affirmative Action and Equal Opportunity Employers, please email recruitment@mercy.com . If you are an individual with a disability and would like to request a reasonable accommodation as part of the employment selection process, please contact The Talent Acquisition Team at recruitment@mercy.com
