RN Case Manager

Job Description

Position Summary:

In collaboration with the interdisciplinary healthcare team, the Case Manager will coordinate the flow of services throughout the patient's hospitalization by means of an established critical pathway or by following InterQual, or other(s) criteria.

Experience:

Must be able to communicate effectively and professionally with a wide cross-section of individuals. Must have high ethical standards with respect to discretion and regarding for confidential information. Will be required to work holidays, weekends. May be required to work shifts other than those which are regularly assigned. Has an understanding of the regulatory requirements relative to the case management process. Certified to complete Patient Review Instruments (PRIs). Has a working knowledge of the hospital computer system as it relates to case management.

Education, License & Cert:

BSN Bachelor Degree: RN Bachelor of Science degree in Nursing (BSN) or, a Bachelor of Arts (BA) degree in addition to a degree in Nursing. A registered nurse with five (5) years relevant experience willing to pursue a BSN or BA degree will be considered. Must obtain BSN within two (2) years of hire. Individual consideration may be given to a registered nurse, with significant clinical experience, who holds a bachelor's degree in a related field.

Essential Functions:

1. Assists to ensure that the right care is provided to patients in the right setting, by the right providers, at the right time, and at the most appropriate cost.

a) Works closely with the Medical Director and other members of the healthcare team to provide appropriate medical management and resource utilization utilizing established/approved criteria.

b) Educates the physician and other healthcare team members regarding the coordination of care processes of the patient across the continuum of care.

c) Participates in an on-call system to ensure 24-hour accessibility and accountability to meet patient needs.

d) Serves as patient advocate in representing the patient's best interests to the providers and payers.

e) Procures insurance authorization where indicated to ensure appropriate, cost effective care. Acts as an institutional advocate by managing care in a cost effective manner and communicating

2. Coordinates medical management through ongoing interaction with the patient and family/caregivers, physician and other health care providers to achieve designated clinical, operational and financial outcomes.

a) Facilitates clinically appropriate treatment and coordinates flow of services by acting as a focal point for communication for healthcare team members, patient, provider, and payer.

b) Maintains accountability for coordination of care processes for the patient during the acute care phase, and during the transition phase to outpatient services.

c) Initiates and participates in patient care conferences as appropriate.

d) Completes nursing assessment forms, i.e., PRI and other referral procedures as needed for continuing care needs.

e) Provides leadership for clinical staff regarding complex patient care concerns and/or care of patients who do not achieve expected outcomes.

f) Documents in a through, concise & timely manner as deemed appropriate by the case manager. Identifies individual patient discharge needs in collaboration with other clinical team members beginning when possible, prior to hospitalization (PAT, Joint Camp) and with the initial assessment and continued reassessment throughout an episode of care. When possible assesses the patient prior to hospitalization and follows-up post discharge in coordination with community agencies. Takes the initiative in working with the interdisciplinary health care team and patient/family to identify a treatment regime which streamlines care, reduces fragmentation and duplication, reduces costs and enhances patient outcomes.

3. a) Assists in the implementation of discharge planning as necessary, through concurrent monitoring and reevaluation, to accommodate changes in treatment or progress. Anticipates changes in treatment and develops contingency plans. b) Ensures patient understanding of rights, choices, and consequences. Completes referral procedures to the appropriate institutional, community, or specialized resources. Integrates patient information, clinical/financial data and operational issues and evaluates the impact upon patient, clinical, and financial outcomes. Identifies opportunities to decrease length of stay and optimize case reimbursement.

4. a) Identifies cost/clinical outlier patients for intensive case management and facilitates evaluation of alternative care options. b) Contributes to Performance Improvement (PI) activities through both individual and aggregate data monitoring. Initiates and provides leadership for performance improvement activities as appropriate based upon outcome data. c) Maintains compliance with documentation requirements and guidelines of third party payers, regulatory and government agencies. d) Participates in long-range planning to meet the needs of the population at risk. Demonstrates leadership skills including effective written and verbal communication, conflict resolution, problem solving and critical thinking, organizational and time management skills and appropriate delegation.

5. a) Provides input in the design and leadership in the integration of clinical pathways and/or practice guidelines and coordinates with other healthcare disciplines to implement, monitor, and evaluate the use of clinical pathways/guidelines. b) Develops and promotes collaborative relationships with other members of the Healthcare team and community resources, including home health agencies DME companies, nursing homes, etc., to explore alternate care options to meet identified patient care issues. 6. a) Maintains a positive and professional relationship with payers that supports continued managed care contracts. b) Articulates the primary objectives of Care Coordination processes to all members of the health care/leadership team. Participates in performance improvement and educational activities. 7. a) Incorporates current evidence based data to identify new resources when gaps exist for continuous improvement of practice patterns. b) Demonstrates knowledge of federal, state and system regulations. c) Serves as an educational resource for other members of the healthcare team in regards to changes in reimbursement and /or utilization requirements. d) Maintains the required hours of continuing exposure to communicable diseases education per year for state license and case management certification as well as department requirements.

Other Duties:

1. Promotes professional growth and development through professional organizations, attendance at seminars / workshops and review of literature.

2. Maintains a current knowledge of regulations and policies of State, Federal and private regulatory and surveying agencies and communicates information through appropriate channels to physicians and other staff as necessary.

3. Participates in Total Quality Training and utilizes principles.

4. Follows patient safety and infection control policies and procedures.

5. Performs other duties as assigned.

6. It is understood that this description is not intended to be all inclusive, and that other duties may be assigned as necessary in the performance for this position.

Pay Range: The per diem rate for this position is $51.10 per hour.

About Us

Joining the Guthrie team allows you to become a part of a tradition of excellence in health care. In all areas and at all levels of Guthrie, you'll find staff members who have committed themselves to serving the community.

The Guthrie Clinic is an Equal Opportunity Employer that welcomes and encourages diversity in the workplace.

The Guthrie Clinic is a non-profit, integrated, practicing physician-led organization in the Twin Tiers of New York and Pennsylvania. Our multi-specialty group practice of more than 500 physicians and 302 advanced practice providers offers 47 specialties through a regional office network providing primary and specialty care in 22 communities. Guthrie Medical Education Programs include General Surgery, Internal Medicine, Emergency Medicine, Family Medicine, Anesthesiology and Orthopedic Surgery Residency, as well as Cardiovascular, Gastroenterology and Pulmonary Critical Care Fellowship programs. Guthrie is also a clinical campus for the Geisinger Commonwealth School of Medicine.

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