Clinical Case Manager
2 days ago
Job Description
The RN Case Manager provides discharge planning and continuity of care for assigned patients in acute and post-acute settings. This role involves coordination of services and acting as a key liaison between patients, families, and interdisciplinary healthcare team members. The RN Case Manager uses utilization management techniques to determine the medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities. This position is responsible for timely regulatory compliance and facilitation of precertification and payer authorization processes when indicated. The RN Case Manager actively participates in clinical performance improvement activities.
Job Responsibilities
- Collects delay and other data for specific performance and/or outcome indicators. Assists in the collection and reporting of resource and financial indicators including acute and post-acute case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials, and appeals.
- Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently. Ensures safe care to patients by adhering to policies, procedures, and standards within budgetary specifications including time management, supply management, productivity, and accuracy of practice.
- Provides discharge planning and continuity of care for assigned patients in the acute and post-acute setting. Initiates and facilitates referrals to clinics, home healthcare, hospice, SNF, acute rehab, LTAC, TCM, medical equipment, and supplies as indicated.
- Collaborates/communicates with internal and external case managers. Understands pre-acute and post-acute resources. Provides coordination of services and acts as a key liaison between patients, families, and interdisciplinary healthcare team members.
- Provides educational resources and/or referrals to patients and patients' families to address identified needs such as social or financial. Acts as an advocate for patients to resolve barriers to care progression.
- Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed.
- Identifies at-risk populations by using approved screening tools and following established reporting procedures. Monitors LOS and ancillary resource use, depending on inpatient stay or outpatient program criteria, on an ongoing basis and takes actions to achieve continuous improvement efficiencies in both areas.
- Participates in the assessment of patients' clinical and psychosocial needs through review of patient information, personal contact with patients/families, and interdisciplinary healthcare team members. Communicates routinely with patients, families, interdisciplinary healthcare team members, and other appropriate parties with regard to the status of patients' care plans and progress toward treatment goals.
- Performs other duties as assigned.
Requirements
Requires Bachelor of Science in Nursing. Associate Degree candidates must obtain BSN within two years of hire. Minimum of one year Case Management experience and/or Clinical Care experience. Basic Life Support through the American Heart Association. Must be licensed in the Commonwealth of Virginia to practice as a Registered Nurse (RN).
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