Case Manager II, Acute

Position Overview:

This position coordinates the utilization management, resource management, discharge planning, post-acute care referrals and care facilitation. This position oversees the management of acute patient populations across the care continuum with a focus to provide coordinated and integrated care to prevent unnecessary admissions or readmissions. Provides discharge planning coordination and Intervention for the high risk patient presenting to the Emergency Department. This position strives to promote patient wellness, improved care outcomes, efficient utilization of health services and minimized denials of payment among a patient population with complex health needs.

Job Description :

These Principal Accountabilities, Requirements and Qualifications are not exhaustive, but are merely the most descriptive of the current job. Management reserves the right to revise the job description or require that other tasks be performed when the circumstances of the job change (for example, emergencies, staff changes, workload, or technical development).

JOB ACCOUNTABILITIES:

Patient Initial and Concurrent Screening.
• Reviews initial physician admission care plan. Gathers additional medical, psychosocial and financial information from the patient/family interview, medical record assessment, physicians and other health care providers. Determines moderate or high risk level for readmission. Conducts a screening for ancillary supportive services.
• Functionally supervises and actively leads the health care team in developing comprehensive, cost-effective care coordination plans that meet the clinical needs of our patients. Performs cost benefit analysis of care options.
• Formulates a transition plan after reviewing available/appropriate care options and obtaining input from the patient/family and physician, health care team, payers and community based support services.
• Identifies and refers quality and risk management concerns to appropriate level for corrective action plans and trending.
• Directs and oversees the Assistants to interview patient/family and determine preferences for post -acute care services.

Utilization Management.
• Completes initial InterQual review screening upon admission for all patients placed in a hospital bed and documents, either inpatient or Observation (OBS) status.
• Performs InterQual continued stay and discharge planning reviews.
• Reviews medical record daily to ensure patient continues to meet level of care (LOC) requirements and that chart documentation supports LOC determination and assignment.
• Works with Physician Advisor and Attending Physicians to obtain necessary documentation to support current LOC, alters LOC as needed and expedites discharge planning for patients who no longer require hospital services.
• Monitors Length of Stay (LOS) and outliers requiring additional resources and/or focus and reports to management.
• Collaborates with financial counselor for delivery of inpatient stay denials.
• Assures delivery of Medicare Important Message within 48 hours of discharge and no less than 4 hours of actual discharge
• Actively participates in patient rounds following the standard work as developed and collaborates with interdisciplinary team to assure timely discharge.
• Maintains an average Utilization Review (UR) accuracy rate at or above the goal.
• Utilizes InterQual criteria for potential/actual admissions to determine appropriateness of the admission, appropriateness of the setting and appropriateness of the level of care.
• Follows policies and procedures for Physician Advisor referrals.
• Facilitates and expedites the discharge of patients from the Emergency Department (ED) to alternate care settings.
• Consistently documents in the Electronic Health Record (EHR) and other electronic software.
• Maintains current knowledge of medical facility and Joint Commission discharge requirements.
• Initiates timely communication with ED/admitting physician when medical necessity deficiencies are identified for level of care ordered.
• Identify avoidable admissions and escalate as appropriate.

Care Coordination/ Care Transitions.
• Performs initial screening on all hospitalized patients upon admission to identify case management needs.
• Performs, documents and communicates assessment findings to health care team.
• Screens 30-day readmissions; reviews previous hospital record confers with interdisciplinary team on discharge plan
• Proactively identifies barriers to discharge and works with multi-disciplinary team to expedite care, monitor length of stay (LOS) and facilitate discharge.
• Addresses complex clinical and social situations efficiently in order to avoid unnecessary delays in discharge.
• completion of treatment plan and transition plan
• modification of plan of care, as necessary, to meet the ongoing needs of the patient
• communication to third party payers and other relevant information to the care team
• completion of all required documentation in electronic health record (including discharge disposition and estimated date of discharge)
• removal of barriers that impede the progression of care
• Proactively identifies and resolves delays and obstacles to discharge.
• Assures timely discharge to lower level of care.
• Assess the need for follow up appointments for high risk patient population and communicated to patient/family prior to discharge.
• Completes necessary paperwork for post-acute transfers to comply with state and federal regulatory requirements.
• Consults with the interdisciplinary team to eliminate barriers to discharge.
• Identifies high utilizers of the ED and makes appropriate referrals to community resources.
• Identifies patient and families with complex psychosocial issues.
• Ensures timely completion of all discharge, transfer, and referral forms.
• Communicates with Financial Counselors regarding uninsured, underinsured and makes referrals, as appropriate.
• Makes appropriate and timely referrals to community agencies, senior services, mental health, and integrate services from ED to community; completes necessary paperwork to comply with state and federal regulatory requirements.

Actively participates in ongoing department operations.
• Actively participates in interviews and recommends selected applicants for hire.
• Serves as a resource for the Assistants.
• Identifies new system, processes, protocols and/or methods to improve practices.
• Actively contributes to the creation of cost effective practices that ensure the best patient experience, effective resource utilization and enhance outcomes.
• Accurately prepares handoff report for the next day.
• Active awareness of Sutter Organization, affiliate, and department communications and strategies from various communication sources
Effectively manages emergency department care coordination services
• Identifies patients appropriate for case management intervention by reviewing the electronic health record (EHR) and meeting with patients and collaborating with staff and physicians.
• Provides feedback to affected personnel/departments with regard to level of care decisions. Escalates cases, as appropriate, to Physician Advisor.
• Effectively follows Observation patients, re-evaluates using InterQual criteria and collaborates with attending physician for admission or discharge of the patient.

Uses effective interpersonal and communication skills to promote customer service with internal and external customers.
• Develops and maintains positive, productive, professional relationships with the healthcare team and representatives of the community agencies.
• Relates with tact and respect to all customers (some of whom may be exhibiting varying levels of distress) with diverse cultural and socioeconomic backgrounds without personal judgment.
• Functionally supervises and positively contributes to the team’s decision making process.
• Willingly provides and accepts direct, constructive feedback to and from colleagues and the leadership team. Actively uses effective communication skills with colleagues to resolve issues in a timely manner.

EDUCATION:
Equivalent experience will be accepted in lieu of the required degree or diploma.

Master's: Social Work or related field

TYPICAL EXPERIENCE:

2 years recent relevant experience.

SKILLS AND KNOWLEDGE:

A broad knowledge base of health care delivery and case management within a managed care environment.

Comprehensive knowledge of Utilization Review, levels of care, and observation status.

Working knowledge of laws, regulations and professional standards affecting case management practice in an integrated delivery system: including but not limited to CMS, Title 22 CHA Consent Manual, CDPH and The Joint Commission (TJC)

A broad knowledge base of post-acute levels of care and associated regulatory compliance requirements.

Must be able to effectively communicate with, and promote cooperation and collaboration between individuals including patients/families/caretakers, physicians, nurses and other ancillary partners.

Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.

Demonstrates commitment to service excellence in all patient, family and employee interactions and in performing all job responsibilities.

Functions in a manner to promote quality patient care and assure a positive patient experience.

Verbal and written communication skills.

Interpersonal communication and negotiation skills.

Must have time management skills to develop organized work processes in a high-volume environment with rapidly changing priorities.

Intermediate computer skills.

Ability to promote teamwork and to effectively function in teams.

Ability to interact effectively with key internal and external constituents using collaboration, and customer service skills that promote excellence in the patient experience.

PHYSICAL ACTIVITIES AND REQUIREMENTS:

See required physical demands, mental components, visual activities & working conditions at the following link:

Job Shift:

Days

Schedule:

Full Time

Shift Hours:

8

Days of the Week:

Variable

Weekend Requirements:

Rotating Weekends

Benefits:

Yes

Unions:

No

Position Status:

Non-Exempt

Weekly Hours:

40

Employee Status:

Regular

Number of Openings:

1

Sutter Health is an equal opportunity employer EOE/M/F/Disability/Veterans.

Pay Range is $52.14 to $68.82 / hour

The salary range for this role may vary above or below the posted range as determined by location. This range has not been adjusted for any specific geographic differential applicable by area where the position may be filled. Compensation takes into account several factors including but not limited to a candidate’s experience, education, skills, licensure and certifications, department equity, training and organizational needs. Base pay is just one piece of the total rewards program offered by Sutter Health. Eligible roles also qualify for a comprehensive benefits package.

Qualified applicants with arrest and conviction records will be considered for employment. Applicants for specific positions are still required to disclose certain convictions during the application process, and those convictions may also be considered in determining eligibility for employment in accordance with applicable law.

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