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Clinical Nurse Case Manager
2 months ago
Department/Unit: Care Management/Social Work
Work Shift: Day (United States of America)
The Clinical Nurse Case Manager is responsible for leading the interdisciplinary team to strategize, coordinate, implement, and assess patient care for the designated service line throughout the care continuum. This role requires proactive collaboration with Quality Improvement Teams, adherence to patient care standards, and effective utilization management to ensure optimal clinical and financial outcomes.
Key Responsibilities:
- Assist the attending physician and interdisciplinary teams in ensuring seamless care coordination throughout the hospital stay, from pre-admission to post-operative phases.
- Continuously monitor patients' clinical pathways in accordance with established care standards and evidence-based practices to facilitate timely and appropriate interventions, ensuring optimal patient outcomes within financial parameters.
- Engage in collaborative care management with primary nursing staff to assess discharge planning needs, coordinate necessary resources, and evaluate the effectiveness of discharge strategies, initiating this process upon admission.
- Work alongside the healthcare team and relevant departments to manage care across the continuum, including pre-admission, discharge, post-discharge, length of stay planning, and resource utilization.
- Leverage specialized knowledge and evidence-based guidelines to provide leadership and direction to the healthcare team in developing individualized multidisciplinary care plans, encompassing pre-hospitalization, acute care, discharge education, and community resource utilization.
- Facilitate and participate in care conferences for patients with complex needs, ensuring effective patient and family education and promoting continuity of care for optimal outcomes.
- Demonstrate proficiency in the referral process and utilization of community resources.
- Analyze admission screening data to clarify diagnoses, establish appropriate lengths of stay, and identify potential outliers, ensuring adherence to institutional standards and evidence-based guidelines.
- Communicate with payer sources to confirm benefits and conduct concurrent reviews.
- Identify capitated patients to determine appropriate service utilization and coordinate post-hospital care based on established standards.
- Recognize high-risk patients based on clinical and financial criteria, collaborating with patient financial services to explore available resources.
- Ensure that all medical/legal documentation is accurately maintained in patient records.
- Adhere to regulations set forth by third-party payers, including compliance with notices of non-coverage and continued stay requirements.
- Collaborate with the healthcare team to implement strategies aimed at reducing length of stay and resource consumption, optimizing patient health status for assigned service patients.
- Assess educational needs and provide training opportunities for healthcare professionals relevant to specific cases and patient care groups.
- Work with case management leadership to compile and report aggregate variances and data for specific patient care services.
- Communicate and analyze aggregate variances with healthcare team members, developing strategies for variance reduction.
Minimum Qualifications:
- Current registered nurse license.
- Bachelor's degree preferred.
- A minimum of three years of clinical experience in a relevant service area.
- Recent experience in case management, utilization management, and/or discharge planning in a high-volume acute care setting preferred. Certification in PRI and Case Management is a plus.
- Demonstrated effective communication, facilitation, and organizational skills.
- Ability to approach problem-solving with assertiveness and creativity, employing critical thinking and systems planning in patient care management.
- Self-motivated with the capacity to adapt to a dynamic environment.
- Basic knowledge of computer systems relevant to the utilization review process.
Albany Medical Center is an equal opportunity employer.
This position may involve access to sensitive information pertaining to Albany Medical Center, its patients, affiliates, and partners, including HIPAA Protected Health Information and other federally and state-regulated information. Workforce members are expected to ensure that access to information is based on a "need to know" basis and is the minimum necessary to perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts shall be made to protect information from unauthorized access and modification.
