Nurse Case Manager
22 hours ago
Nuvance Health is seeking a skilled Nurse Case Manager to join our team. As a key member of our care coordination team, you will play a vital role in ensuring the delivery of effective and efficient patient care.
Key Responsibilities- Provide clinically-based case management to support the delivery of effective and efficient patient care.
- Pace cases from physiological and economic perspectives.
- Have overall accountability for the utilization management and transition management for patients within the assigned caseload.
- Partner with Social Workers and collaborate with other healthcare team members to identify appropriate utilization of resources and to ensure reimbursement.
- Utilize criteria to confirm medical necessity for admission and continued stay.
- With the patient, family, and healthcare team, create a discharge plan appropriate to the patient's needs and resources.
- Determines medical necessity, appropriateness of admission, continuing stay, and level of care using a combination of clinical information, clinical criteria, and third-party information.
- Intervenes when determinations are not in alignment with clinical information, clinical criteria, computer system, or third-party information to resolve the situation.
- Documents information in the current electronic system (such as MIDAS).
- Validates admission and continuing stay criteria with third-party payers (including onsite and telephonic Case Managers) as well as Primary Care and Attending Physicians.
- Recommends alternative care sites where appropriate.
- The observation cases are a priority, and at a minimum, the case manager reviews observation cases daily.
- Utilizes physician advisor to interface with physicians as needed.
- Collaborates with the third-party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial.
- Intervenes to prevent the denial where possible.
- Supports the effective prevention and management of denials, including providing information as part of the appeal process.
- Serves as the lead in obtaining financial and other resources for patients/families in need.
- Assesses the patient and family for continuing care needs to develop, implement, and evaluate an effective discharge plan in collaboration with the multidisciplinary team.
- Uses knowledge of usual length of stay to initiate a plan for discharge.
- Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan.
- Supports the process of patient choice in establishing a discharge plan.
- Uses clinical knowledge and knowledge of anticipated response to treatment to assess patient progression towards anticipated outcomes.
- Communicates and coordinates with the patient/family and healthcare team to intervene when progression is stalled or diverted.
- Addresses actual/potential barriers to discharge.
- Provides support and counseling to patients/families experiencing and/or anticipating issues to adjusting to illness, catastrophic diagnoses, changes in living situations, and bereavement.
- Establishes a plan and documents interventions and outcomes.
- Completes the interventions necessary for discharges to home with self-care, home with services, and short-term skilled nursing facility placement.
- Assembles necessary referrals, discharge summaries, and pertinent information for placement prior to the day of discharge.
- Consults, assesses, refers, coordinates interventions in cases of suspected or actual situations of child or adult abuse and neglect or other forms of domestic violence and/or sexual abuse.
- Actively contributes to and participates in length of stay meetings, discharge planning rounds, during unit daily report, clinical practice teams, and department meetings.
- Identifies high-risk patients and creates a collaborative plan to address their unique needs.
- Serves as the lead in obtaining legal guardianship and competency determinations as well as adoption-related situations.
- Completes and disseminates all necessary legal and clinical documentation as required.
- Must have strong interpersonal and communication skills.
- Ability to form positive, collaborative relationships with hospital staff, patients, and families.
- Ability to effectively negotiate with internal and external providers of patient care services.
- Must have analytical abilities to assist in obtaining solutions to problems.
- Must be able to work independently and prioritize work.
- Must be able to manage multiple priorities.
- Basic knowledge of computers and clinical applications.
- Ability to problem-solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge.
- Ability to effectively negotiate with internal and external providers of patient care services.
Ability to speak and write English to the extent necessary for safe and efficient performance of the job.
Minimum Requirement- 3 years of experience in acute care.
- Must have Associate's Degree or BSN preferred.
- Must have current RN license.
- Preferred experience in Utilization Review/Management.
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