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DESCRIPTION:
Hospital based Case Manager coordinates and manages patient care to ensure continuity of care delivered with compassion, excellence, and reliability. The Case Manager collaborates with the physicians to evaluate, prepare, educate, and refer patients for the next level of care and works closely with ancillary services to assist in arranging placement in the appropriate care setting as well as coordinates a safe and timely discharge plan. The Case Manager performs case management through direct referrals and reviews of medical records. Facilitates and participates in organizational quality improvement activities including treatment plan assessments, discharge planning, and coordination of care.
ENTRY REQUIREMENTS:
Bachelor of Science in Nursing Preferred
Current licensure as Registered Nurse in the State of Michigan.
Minimum 3 years progressive experience in a clinical setting required, including at least 2 years as a Registered Nurse.
Case Management Certification preferred. Certification is encouraged and may be obtained within 2 years of employment in the job.
Skills, Talents and Abilities: Individual must be detail oriented, have computer application experience as well as excellent written/oral communication skills. Must be able to work cooperatively as a member of a team, able to communicate effectively with patients and their families as well to all levels of the hospital staff. Must be flexible, self-motivated, interested in program development and capable of making independent decisions. Ability to be non-judgmental and work with those holding diverse opinions, religions and cultural values. Significant analytical ability is required; must be accurate, concise and detail oriented.
Physical Efforts: Must be able to balance, bend, climb, crawl, crouch, kneel, reach, sit, squat, stand, twist and walk 100% of the time. Must be able to hear speech, distinguish sounds and speak. Must have near vision, far vision, depth perception and be able to distinguish colors.
SPECIFIC DUTIES:
Supports the Mission, Vision and Values of Munson Healthcare
Embraces and supports the Performance Improvement philosophy of Munson Healthcare
Promotes personal and patient safety
Uses effective customer service/interpersonal skills at all times and follows the commitment to coworkers.
Clinical expertise and critical thinking skills: Provides a competent patient assessment by obtaining and interpreting data, making appropriate decisions based upon knowledge and experience and, if applicable, adapting plans accordingly. Utilizes critical thinking in all interactions in order to identify variances/problems and apply sound decision-making skills.
Excellent assessment skills: Displays excellent assessment experience and skills by utilizing evidence based practice knowledge and skilled intervention in order to effectively prioritize and complete comprehensive assessments and facilitate appropriate care coordination.
Case management skills with good follow- through: Possesses case management skills to effectively manage all cases per established organizational standards. Facilitates care coordination and ensures continuity of services in order to meet patients, family and staff needs.
Strong interpersonal communication skills: Displays active listening and empathetic communication skills with patients, families and staff. Engages and collaborates with patients, families, multi-disciplinary staff and the community in
care planning, delivery and discharge. Builds solid relationships, negotiates effectively and works well with individuals of all ages, backgrounds and socioeconomic position.
Assess and documents the resources and cost of services, providers available with home care benefits.
Interacts with the patients and families in the development of the comprehensive and timely transitional plan that is realistic, patient oriented and time specific.
Enacts transitional plan that moves the patient along with the care continuum, effectively working with the community to identify and allocate post discharge needs.
Develops collaborative relationships with providers including those pertaining to vocational needs and disability compensation.
Participates in concurrent performance improvement efforts to assist in implementing the measure that impact quality care outcomes.
Admission:
a. Reviews available documentation to assess all admissions for appropriate status and services according to patient condition and diagnosis.
b. Applies standard guidelines to determine appropriateness for inpatient level of care or observation services based on documented condition plan of treatment and care.
c. Supports physician decision-making by coaching on appropriateness of inpatient or observation status.
d. Confers with admitting physician if documentation does not support hospital level of care to offer alternatives.
e. Refers cases to the Physician Advisor when documentation is inadequate to support acute level of care and remains unresolved after discussing with referring/attending physician.
f. Understands and applies federal law regarding the use of Hospital Initiated Notice of Non-Coverage (HINN) and Ambulatory Benefit Notice (ABN).
g. Monitors insurer compliance with contractual obligations.
h. Maintains proficiency in the use of electronic review applications including EMR and enters information correctly, consistently and timely.
i. Maintains proficiency in the use of hospital information systems to access information and record data.
Continuing Stay:
a. Actively participate in daily huddles, patient care conferences, and hospitalist/nurses hand-off reports to maintain knowledge about the patient’s clinical status and progression of care.
b. Consults with case manager and/or physician advisor as necessary to resolve progression-of-care barriers through appropriate administrative and medical channels.
c. Identify potentially unnecessary services and care delivery settings and recommend alternatives when appropriate.
d. Collaborates with community physicians and hospitalists to influence transition from one level of care to another.
e. Notifies insurers and third party administrators of clinical review information.
f. Maintains documentation on each patient to include specific criteria that support appropriate level of care and continued stay. Performs status changes as necessary
g. Refers cases to the Physician Advisor when treatment plan documentation does not support acute level of care. Monitors timeliness of PA response.
h. Identify and record episodes of preventable delays or avoidable days due to failure of progression-of-care processes.
i. Promote physicians’ use of evidence based protocols and/or order sets to influence high quality and cost effective care.
Transition:
a. Collaborate with clinical team to confirm benefit eligibility for post-acute services.
b. Apply Interqual discharge screens to assess patient’s readiness for a lower level of care.
c. Updates all involved parties regarding potential, threatened or actual denials due to lack of medical necessity or barriers to the progression of care.
d. Participates in reviewing 30-day Readmissions as directed by program manager.
e. Reviews request for direct admissions and transfers for appropriate level of care.
f. Coordinates with ED Physicians and Hospitalists to recommend alternate placement from the ED when patients do not qualify for Outpatient Observation or Inpatient status including mental health and substance abuse.
Program Support:
a. Serves as a resource person to physicians, case managers, physician offices, and billing office for coverage and compliance issues.
b. Works closely with decision support personnel to review resource utilization data and trends to identify outliers who may benefit from real time coaching to improve outcomes.
c. Encourage healthcare team members in collaborative problem solving regarding appropriate use of resources.
d. Assists in developing and revising policies to support utilization management activities, including criteria and guidelines for appropriate use of services, clinical practice guidelines and treatment protocols.
e. Recognizes and responds appropriately to risk factors.
f. Keeps current on all regulatory changes that affect medical necessity or reimbursement of acute care services and shares that information with program colleagues and hospital associates at information meetings.
g. May represent Utilization Management on various committees, professional organizations, physician or and community groups.
h. Establish and maintain effective professional working relationships with patients, families, interdisciplinary team members, payers and external case managers.
i. Meet DPOA/Legal – Guardianship.
j. Provide substance abuse connections/resources.
k. Performs other duties and responsibilities as assigned.