The Case Manager is responsible to ensure the collaborative process of assessment, planning, facilitation and advocacy for options and services to meet the patient's health needs through communication and available resources to promote quality and cost-effective outcomes.
The Case Manager:
- Manages the patient case from pre-admission through discharge.
- Ensures the Interdisciplinary Team implements agreed-upon, necessary services as outlined in the patient plan of care subject to contract terms and case negotiations in order to minimize over-utilization or under-utilization of services and associated unreimbursed claims.
- Is assigned to one or more centers based on Managed Care case volume. The Dedicated Case Manager performs responsibilities at the site of service while the Stationary Case Manager performs responsibilities at an off-site location.
- Acts as an account liaison on Genesis' behalf with our plan providers.
- Identifies opportunities for quality and performance improvement and communicates to supervisor and/or Administrator.
The Case Managers performs to established productivity metrics which reflect the Case Manager's effectiveness and efficiencies in carrying out responsibilities.
- Based on standard operating procedures, verifies and communicates current, accurate and complete clinical information to payor from patient Pre-Admission through Concurrent Review using standard and plan review forms to justify clinical necessity according to payor review schedule. Ensures documentation is timely, accurate and complete in PCC and field file.
- Reviews Pre-Admission Review (PAR) and IRM Pre-Authorization assessment to identify costly treatments, supplies or services.
- Negotiates for appropriate continuation of length of stay or extension of services and appropriate Level of Care (what is covered/what is not covered) and associated rates.
- Facilitates obtaining payor authorization for recommended treatments, procedures, supplies, equipment and medications and all exclusions
- Reviews Admission orders on all managed care patients for appropriateness. If necessary, re-negotiates Length of Service and Level of Care.
- Communicates contract terms for patient's stay to Interdisciplinary Team, e.g. Level of Care, Length of Service, Utilization of Services, Inclusions and Exclusions, Revenue Per Day, Network Providers, Rehab Treatments
- Actively monitors patient case throughout stay to ensure utilization of services are in accordance with plan of care and minimize financial risk to patient and center.
- Acts as resource to Physicians, NPs and Treatment Team to identify alternate, cost-effective treatment options
- Liaises with appropriate staff to gain or provide information, e.g. CRC, Unit Manager, Social Worker, Business Office, Rehab Program Manager.
- Reviews Rehab Optima (ROX) Documentation and clearly document current clinical and discharge planning information sent to payer and maintain in field file
- Actively participates in weekly Utilization Meeting.
- Alerts appropriate staff and vendors of non-covered services.
- Alerts appropriate staff when duplicate services are ordered.
- Monitors changes in status that could lead to hospital readmission and report to nursing.
- Identifies overuse of resources such as rehabilitation therapy, diagnostic studies, non-formulary medications and medical supplies
- Alerts Center Designee to last covered day of service. Requests Notice of Non-Coverage be delivered to patient/family for signature with copy of notification in Center Financial File.
- Assists Center in responding to denial of continued services by providing clinical information that substantiate medical necessity. Writes clinical appeals to insurance plans as needed.
- Prepares patient case for discharge/transition by ensuring network providers are known and securing all appropriate authorizations for a safe, coordinated discharge for patient/caregiver.
- Assesses patient/family risk factors as it relates to resource utilization: chronicity, complications and co-morbidity and identify barriers to a timely discharge.
- Consults Social Worker immediately for all social, customer/family problems that are identified as barriers to a timely, appropriate discharge.
- Maintains comprehensive case management records on all customers that reflect authorizations, extensions, levels of care, dates of service and rates approved by the payer to include name, phone and date of payer case manager's authorization.
- Manages relationships with 3rd party payors ensuring timely responses.
- Resolves issues promptly
- Identifies service delivery and process improvements and communicates to supervisor.
For Dedicated Case Managers, additional support may be provided directly to patient/family and/or caregiver with respect to:
May develop and implement discharge plan to include responsibilities of nursing, rehab and social service staff and communicate plan to patient/caregiver as necessary.
May participate in Family Care Meetings and may provide additional support to patient/caregivers as needed.
Create and distribute Adverse Determination and/or 48 Hour Notification Letter to patient.
SPECIFIC EDUCATIONAL/VOCATIONAL SPECIFIC EDUCATIONAL/VOCATIONAL REQUIREMENTS: 1. Graduate of an accredited School of Nursing with current RN licensure in the state where employment occurs or where case management is practiced contingent upon state regulations required. Bachelor's Degree in Nursing preferred. Certified Case Management (CCM) or related clinical certifications also preferred. 2. Five years of recent clinical nursing experience required. Prior experience in utilization review, case management or discharge planning required. 3. Prior experience using evidence-based clinical decision support criteria (e.g. Interqual, Milliman) 4. Experience in rehabilitation nursing, acute care and/or the insurance field preferred. Two years full time experience in case management which includes service to short/long term facility based clients preferred. 5. Valid driver's license and automobile with appropriate insurance required. 6. Advanced knowledge of third party reimbursement, insurance coverage and contract requirements. JOB SKILLS: 1. Advanced communication skills, oral and written. Communicate clinical data and knowledge clearly to internal and external customers Asks tough, pertinent questions to understand case. 2. Advanced understanding of Managed Care and other third party reimbursement plans - indemnity, managed indemnity (HMO, PPG, DRG, coinsurance, Medicare (Managed, Fee for Service, Other) and contract requirements and risk-sharing methods. 3. Advanced understanding of denials, reconsiderations, expedited/standard appeals, pre-certification, concurrent review, and retrospective review. 4. Advanced case management skills necessary to ensure appropriate patient care, payor reimbursement and an appropriate discharge. 5. Advanced negotiation skills - uses assertiveness and conflict resolution when appropriate. Communicates and ensures an accurate assessment of the patient's condition and resources available to achieve approval for the correct level of care and / or length of stay for each patient. 6. Long-standing, positive relationships with plan liaisons realized through favorable outcomes negotiated with little or no effort. 7. Advanced organizational and time management skills. Creates appropriate prioritization of multiple tasks and duties. Comfortable working in a fast paced, unstructured environment. 8. Advanced strong interpersonal skills to participate in meetings telephonically, to secure appropriate chart information when working remotely, and to effectively problem solve. 9. Proficient in using proprietary computer systems and Microsoft Suite (Word, Excel, Outlook) to support creation/maintenance of electronic medical record and effective communications. PERFORMS RELATED DUTIES: 1. Works with Center Interdisciplinary Care Team to integrate principles of managed care. 2. Establishes collaborative relationships with members of Genesis HealthCare , contracted providers and referral sources. 3. Assesses customer satisfaction and compliance with services. 4. Communicates issues and concerns with appropriate personnel.