POSITION SUMMARY The purpose of the Case Manager position supports the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates and coordinates the functions of utilization management, care progression and care transition.
The Case Manager is accountable for a designated patient caseload and plans effectively to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include:
- Facilitation of precertification and payor authorization processes
- Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement
- Application of process improvement methodologies in evaluating outcomes of care
- Coordinating communication with physicians.
The role reflects appropriate knowledge of RN scope of practice, current state requirements, CMS Conditions of Participation, EMTALA, The Patient Bill of Rights, AB1203 and other Federal or State regulatory agency requirements specific to Utilization Review and Discharge Planning. The Care Manager partners with the medical staff, utilizes scientific evidence for best practices, and relevant data to manage the care of the patient over the continuum of their hospitalization. These activities include admission, continued, extended and discharge reviews in all reimbursement categories to determine medical necessity, assure high quality of care and efficient utilization of available healthcare resources, facilities and services. This position requires the full understanding and active participation in fulfilling the Mission of Martin Luther King, Jr. Community Hospital. It is expected that the employee will demonstrate behavior consistent with the Core Values. The employee shall support Martin Luther King, Jr. Community Hospital's strategic plan and the goals and direction of the quality and performance improvement process activities.
ESSENTIAL DUTIES AND RESPONSIBILITIES Assessment: - Completes a comprehensive assessment to identify opportunities for intervention that are appropriate and realistic for the patient/family's psycho-social, cultural, spiritual, and physical plan of care.
- Assess the patient's healthcare needs and goals; specifically targeting the physical, functional, psychosocial, environmental and financial status.
- Completes and documents timely clinical reviews based on assessment of medical necessity and documented clinical findings in accordance with Hospital policy and payer requirements.
- Communicates with attending physician regarding appropriateness of patient admissions, resource utilization, and when documentation does not support continued stay.
- Assesses readmission risk based on established Hospital criteria.
Planning: - Demonstrates an understanding of medical necessity and intensity of service, and incorporates payer requirements into the development of a safe, effective, and timely discharge plan.
- Demonstrates an understanding of the patient's clinical condition, social, and financial resources to determine the most appropriate care setting, practice standards for evaluation, treatment delivery options (Home, SAR, SNF,
- LTACH, Acute Rehabilitation, Assisted Living, Board/Care, Recuperative Care, Shelter), and resources required to support safe transition of care.
- Incorporates risk of readmission and socio-economic factors in the creation of a safe and individualized transition plan.
- Engages the patient and family/support network in developing the transition plan.
- Collaborates actively with the interdisciplinary team throughout the patient's stay to re-assess and adjust the plan for care progression and transition according to the patient's clinical condition.
- Advocates for the patient with the payer and/or IPA to ensure the most effective care progression and transition plan for the patient.
Implementation: - Coordinates the progression of care to ensure that the ongoing needs of the patient and family are adequately addressed.
- a.Identifies psychosocial and financial barriers, (e.g. substance abuse, homelessness, unsafe or abusive living arrangement) and collaborates with or delegates to Clinical Social Work colleagues.
- b.Identifies discharge planning needs and facilitates transfers to acute and post-acute venues.
- c.Demonstrates working knowledge of the clinical requirements, individual payer networks and coverage, and impact of patient's living environment and support network in creating a transition plan.
- d.Identifies and facilitates home care and durable medical equipment needs at the time of discharge.
- e. Facilitates palliative or hospice care when needed
- Works collaboratively and maintains active communication with physicians, nursing and other members of the interdisciplinary care team to ensure timely and effective care progression and achievement of desired outcomes.
- Oversees discharge planning and facilitates safe transitions to community settings.
- Addresses/resolves system problems impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles to discharge.
- Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge.
- Coordinates and monitors scheduling of tests/procedures of patients and reports results to other healthcare members when appropriate. Identifies recurrent problems and recommends strategies for resolution.
Evaluation - Develops and evaluates case management plans and protocols in collaboration with the interdisciplinary team.
- Evaluates actions taken to assure cost-effective care including physician length of stay, diagnostic related groups cost reporting, morbidity and mortality reports and monitoring of readmissions.
- Utilizes avoidable day reporting tool to identify sources of barriers to patients' progression of care.
Communication/Collaboration: - Serves as a liaison between members of the interdisciplinary care team, community providers, payers, and patient/family to ensure safe and effective plans and smooth transitions between internal and external levels of care.
- Ensures consistent and timely communication with Patient Financial Services and HIM as needed to confirm patient status and/or authorization to support the billing process.
- Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care.
- Collaborates with attending physicians and consultants to review and discuss patient care, progress and identified outcomes. Defines and manages deviations from the plan of care.
- Participates in and or facilitates patient care conferences and family meetings.
- Provides support and clinical expertise for nursing/ancillary personnel related to patient care issues.
- Maintains communication with Nurse Managers and other Case Managers relative to individual patient care and/or system problems.
- Assures prompt reporting of medical/legal issues to Risk Management and appropriate Administrative parties.
- Facilitates peer to peer discussions between attending physicians, Case Management Consultants, and Physician Advisor in cases requiring evaluation and justification of medical necessity for admission by the payer.
- Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
Professionalism: - Within the nursing scope of practice, the care manager continuously assesses self-knowledge and competencies to assure job performance.
- Actively participates in departmental meetings and shares knowledge related to the practice of case management
- Demonstrates understanding of Medicare Conditions of Participation as related to discharge planning, patient/family engagement, and communication of financial responsibility.
- Maintains respect for the dignity of every person by addressing issues and concerns with workers directly, with a positive problem-solving approach, and the observance of the right to patient privacy and confidentiality.
- Demonstrates concern, respect, and caring for all customers, both internal and external, regardless of their diagnosis or socioeconomic status.
- Maintains positive interpersonal relations.
- Performs other related job duties as assigned.
POSITION REQUIREMENTS A. Education
- Bachelor of Science degree in nursing preferred
B. Qualifications/Experience
- Minimum of one (1) to three (3) years of hospital or related experience required. Internals with at least 18 months acute care case management/coordination experience will be considered in lieu of nursing clinical experience.
- Able to navigate and connect successfully with outside provider networks (Health Plans, IPA's, and FQHC's).
C. Special Skills/Knowledge
- Bilingual language skills preferred (Spanish) Basic computer skills
- Current California Nursing license
- Current Basic Life Support (BLS)
- Certification in Case Management preferred.
- ED Care Managers: Must complete annual Workplace Violence Prevention Program/Certificate, per hospital policy, during initial training/orientation but not to exceed 90 days from hire/transfer.
