Review and facilitation of the Continuum of Care to achieve desired clinical outcomes. Outcomes attained collaboratively with participation of patients, family members, physicians, health care providers and others.
3-5 years minimum experience working in case management
Maryland Nursing License or License General Social Worker
Certified Case Manager preferred
Knowledge, Skills & Abilities
Ability to comprehend and follow the policies and procedures for MedStar Southern Maryland Hospital Center.
Ability to read, write and speak or communicate in English to successfully accomplish the essential duties of the position.
Ability to demonstrate ethical behavior that supports the hospital’s mission, values and commitment to compliance with all federal, state and regulatory laws. Inspires trust and exhibits honesty and integrity within the scope of daily activities.
Exhibits professionalism, courtesy and excellent customer service, while interacting with patients, guests and co-workers.
Ability to work effectively with people from a variety of culturally diverse backgrounds.
Ability to maintain patient confidentiality.
Knowledgeable of MedStar Southern Maryland Hospital Center’s performance improvement priorities and outcomes.
Knowledge of Joint Commission, State and federal regulations as it pertains to Case Management.
Ability to set priorities to maximize the overall effectiveness of the function and complete assignments within scheduled hours.
Demonstrate initiative in acquiring knowledge to further understand the overall department and hospital functions.
Ability to contribute through constructive suggestions and illustrate resourcefulness.
Ability to demonstrate responsibility for work performance, consistent good attendance, and resourcefulness to solve case management problems.
Knowledge and ability to use a desktop/laptop computer.
Primary Duties and Responsibilities
Performs integrated patient care quality monitoring:
Utilizes Medical Staff approved comprehensive monitors that measure/evaluate:
Operative and Invasive procedures
Stability at Discharge
Immediately notifies the Quality and Accreditation Improvement Department of urgent/critical quality issues.
Identifies cases for potential peer review and reports these cases to the Quality and Accreditation Department.
Documents all screening and outcome variations according to Quality & Accreditation Department process.
Assists MSMHC achieve compliance in the important functions described in the Joint Commission manual.
Performs utilization review, regardless of payor source, in accordance with the Utilization Management Plan in accordance with State of Maryland Regulations.
Utilizes Medical Staff approved monitors for ongoing measurement/evaluation of utilization management
Completes, in a timely manner, admission and continues stay criteria review to obtain “certification” and/or continues stay approval for selected Medicare, Medicaid, commercial and managed care patients.
Refers individual patient reviews that do not meet status criteria to Executive Health Resources as per contract.
Readily distinguishes between acute, intermediate and skilled levels of care.
Contacts managed care companies on a daily basis to assure reimbursement for continued stay.
Refers concurrent utilization problems/issues to the Physician Advisor for review.
Performs the “denial” process for all patients according to particular payor.
Advises the physician of appropriate commercial insurer requirements, such as Medical Assistance second opinion requirement.
Performs clinical review, upon request of Patient Accounts, for appeals, and Medicaid Administrative Days.
Completes appeal process for denial days that appear to be clinically justified.
Maintain current clinical records according to department policy and professional standards and prepares monthly statistical reports.
Is available on a rotating basis on weekends, evenings, and holidays with other staff to provide onsite services from utilization review.
Facilitates the “Continuum of Care” through coordination of the discharge planning process:
Interview/counsel patients, families, significant others for the purpose of assessing psychosocial functioning and discharge planning needs specific to that patient.
Upon referral, assess patient discharge planning needs and social factors related to patient care. Consults with the physician(s) to obtain essential information including the post discharge treatment plan and communicates this treatment plan to other health care providers, internal and external, to assure the continuity of the patient’s care.
Ability to coordinates multi disciplinary clinical management conferences.
Assists the patient and significant other in assessing discharge options and determining a plan for continuing care within the limits of resources, personal preferences, regulations, and medical needs.
Documents assessment, discharge plan, problems, services, and outcomes in the medical record in a clear and concise manner with consideration of the patient’s age, developmental needs, diagnosis and employee area of specialization.
Makes referrals and arranges for needed services for home care.
Arrange DME, ambulance service, home care, and respiratory care as medically indicated.
Counsels patients and significant other regarding financial assistance and makes appropriate referrals where needed.
Assesses level of care for patients in need of long term placement and obtains appropriate placement.
Coordinates long term or short term placement with the physician, patient, significant other and internal/external health care providers.
Maintains current clinical records according to department policy and professional standards and prepares monthly statistical reports.
Is available to be on site on a rotating basis on weekends, evenings and holidays with other staff to provide discharge planning, telephone consultation, resource information and referrals for Home Health and medical equipment.
Assures the provision of clinical social services to meet the needs of our patients and their significant others:
Makes appropriate referrals to Pastoral Care to meet the spiritual needs of our patients and significant other.
Makes appropriate referrals to community action groups, support groups, etcetera.
Complies with the State law for reporting abuse/neglect for children and adults.
Communicates with others in an effective, professional manner:
Maintains confidentiality in accordance with hospital policy.
Maintains open communication with MSMHC staff, Medical Staff, patients, significant others, nursing and health care providers as appropriate, (internal and external) to facilitate the case management process and enable patients to make informed decisions regarding their plan of treatment and discharge disposition.
Communicates effectively, courteously and compassionately with all patients, families, visitors, physicians.
Utilizes appropriate channels of communication to address interdepartmental concerns and opportunities for improvement.
Serves as patient advocate in assuring a collaborative approach to patient care management.
Participates in organizational improvement:
Participates in improving processes related to the Continuum of Care, Performance Improvement, and The Joint Commission Important Functions as appropriate.
Participates in the formulation and revision of policies and procedures related to the case management process.
Demonstrates a commitment to professionalism and self-improvement:
Attends required departmental staff meetings.
Participates in the Joint Commission related educational programs.
Participates in related educational programs that promote clinical and case management expertise.
Participates or provides at least one educational program annually for MSMHC staff.
Accepts other related duties as assigned by the Director.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation and research. Our 30,000 associates and 5,400 affiliated physicians work in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest visiting nurse association in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar is dedicated not only to teaching the next generation of doctors, but also to the continuing education and professional development of our whole team. MedStar Health offers diverse opportunities for career advancement and personal fulfillment.