Description:
Facilitates the patient's hospitalization from pre-admission through discharge by assessing each patient for discharge needs and coordinating services to meet those needs. The Case Manager coordinates with physicians, nurses, social workers, and other health team members to expedite medically appropriate cost-effective care. The Case Manager applies clinical expertise and medical appropriateness criteria to resource utilization and discharge planning. Performs utilization reviews in accordance with established Hospital UR Plan. Will advise the health care team and provide leadership as needed.
Job Results & Essential Function
Care Plans that Address Patient Needs
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Screens admissions according to established criteria, assessing their conditions and needs in order to develop personalized care plans. Regularly evaluates the plan of care and updates them on an as-needed basis.
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Accepts referrals in coordination with other case managers.
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Coordinates the provision of social services and discharge planning to patients, families, and significant others, enabling them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from health care services.
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Fosters team planning of patient care services.
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Chairs multidisciplinary team meetings.
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Performs chart reviews using Interqual criteria.
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Review of DRG assignments.
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Provides clinical information to insurance companies upon request.
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Notifies Infection Control Practitioner of patients admitted with infectious disease.
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Maintains a record in each referred patient's chart including an initial assessment and ongoing case activity.
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Provides supportive counseling, information, and referral to patients dealing with illness-related problems.
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Provides services to Emergency Room, ambulatory surgery, maternity, and outpatients upon request.
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Contacts the Medical Director or UR Physician of UR issues as needed.
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Collects pertinent and timely data and uses it to improve outcomes.
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Focuses on strategies that result in reducing complications, morbidity, and mortality.
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Performs UR reviews as assigned.
Referrals to Services
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Coordinates the referral of patients and families to appropriate community, social services, residential care and rehab facilities and organizations.
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Meets with the patient and/or family to ascertain needs and provide and/or arrange for services.
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Assists patients and families with evaluation and placement in Long Term Care Facilities.
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Completes home care and DME referrals.
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Ensures staff awareness of services available by maintaining current lists of agencies.
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Maintains a log of insurance company contacts.
Effective Collaboration that Helps Achieve Organizational Goals
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Participates in department and/or system-wide team dynamic initiatives.
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Provides day-to-day support of workflow within the work unit; including disseminating information, assigning staff to cover for absences, providing technical assistance, answering questions, and resolving problems as directed by the Supervisor of Clinical Support.
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Acts as a team player and works collaboratively within the team and organization.
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Assists with developing priorities, goals, and action plans.
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Responds to requests from Clinical Supervisor.
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Collaborates with interdisciplinary teams to assist with the evaluation of programs and services.
Process Improvement
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Optimizes the provision of quality healthcare that meets the interests of consumers, providers, and payers.
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Identifies better, faster, more efficient ways of doing tasks as well as eliminates unnecessary work and all non-value-added activities to enable a focus on work that generates greater value.
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Responds to requests from Clinical Supervisor, and collaborates with interdisciplinary teams to assist with the evaluation of programs and services. Communicates with Supervisor regarding cost savings initiatives and planning.
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Utilizes understanding of regulatory requirements to identify ways to improve process quality and compliance.
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Actively participates in Core Measure Process.
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Completes chart reviews for performance improvement studies.
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Responsible for ensuring patients safety and reporting any concerns to the Director of Quality
Requirements:
Education & Experience
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Bachelors’ degree in Social Work or related field preferred.
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At least two years (2) experience working as a Case Manager in an acute care hospital environment.
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Critical care or emergency room experience desired.
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Knowledge of regulatory agencies.
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Advanced communication and interpersonal skills with all levels of internal and external customers. This includes, but is not limited to government agencies, third-party payers, intermediaries, the medical staff, patients and families, clinical personnel support, and technical staff.
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Demonstrated skills in the areas of negotiation, conflict resolution, interdisciplinary collaboration, creative problem solving, and critical thinking.
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Knowledge of healthcare financing, community and organization resources, patient care processes, and data analysis.
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Knowledge of utilization management as it relates to third-party payers.
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Ability to demonstrate flexibility and adapt to changing priorities and regulations.
Licenses and/or Certifications
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Current licensure in NYS as an RN
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PRI and Screen Certification preferred
Physical Demands
Frequent walking, sitting, standing; use of the computer.
Language Ability
Ability to read, write and interpret documents in English such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to read, analyze and interpret common scientific/trade/technical journals. Ability to respond to common inquiries or complaints from customers, or regulatory agencies. Ability to write reports, business correspondence, and procedure manuals. Ability to speak effectively before groups of employees, patients, and vendors.
Math Ability
Ability to add, subtract, multiply and divide into all units of measure, using whole numbers, common fractions, and decimals. Ability to calculate figures and amounts such as proportions, percentages, rates, and ratios.
Reasoning Ability
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Ability to interact with Case Management staff, patients, patient’s families, other hospital departments, outside agencies, insurance companies, and physicians.
Working Conditions
Most work is conducted in a well-lighted, ventilated, office and on the Progressive Care Unit. Potential exposure to chemicals and communicable diseases and related medical waste.
