General Summary Statement
Responsible for the coordination of a multidisciplinary plan of care ensuring the delivery of quality patient care that facilitates discharge and expected outcomes, utilizing appropriate and cost effective strategies. Performs and communicates clinical reviews and data to insurance payors. Collaborates with health care team to streamline patient care. Identify system barriers to cost effective quality care.
Essential Duties and Responsibilities
1. Communicates patient needs to medical staff, nursing staff, Case Management team and payers, as appropriate
2. Communicates patient needs with attention to detail to service providers to ensure safe level of care and appropriate resources after discharge.
3. Communicates with medical staff regarding case management issues as they occur and document accordingly.
4. Communicates with ancillary departments to: negotiate accelerated test scheduling, receive results not yet available on medical record or ensure interaction with patient as ordered by physician.
5. Relays identified risk, infection control or patient concern issues to Risk Manager, Infection Control Practitioner, or Customer Service Coordinator as appropriate.
1. Discusses the plan of care and targeted length of stay with the multidisciplinary team, patients, and family at the time of admission.
2. Explores strategies to reduce the length of stay and resource consumption.
3. Serves as a patient advocate with the health care team, payors and outside agencies.
4. Collaborates with primary nurses to identify plans to maintain streamlined patient care.
5. Participates in the daily discharge rapid rounds (multidisciplinary team meetings) coming prepared with essential information.
6. Identifies a plan with the Case Management Director and/or Team Lead to address system opportunities and participates in that plan.
Utilization Review Competencies
1. Performs clinical reviews on assigned patients. Communicates reviews to insurers in a timely manner to ensure maximum reimbursement.
2. Performs continued stay reviews.
3. Performs daily insurance certification activities for designated commercial insurance, Medicaid, and upon request by third party payer.
4. Understands and utilizes Inter Qual review criteria.
5. Communicates proactively with the medical staff regarding any potential/actual altered payment situations on the same day it is identified by the Case Manager.and payer.
6. Manages denials in accordance with the established protocols and procedures.
7. Concurrently assesses patients’ progress or lack of progress and implements strategies to streamline care.
8. Coordinates referrals to Physician Advisor and/or EHR to establish medical necessity.
Discharge Planning Competencies
1. Interviews and collaborates with patient/family to assess aftercare options providing guidance information and support in decision making.
2. Develops alternative discharge plans and coordinates with Team Leader, peers, and/or Social Worker as needed to facilitate resolution of problem dispositions or difficult patients/families.
3. Facilitates and monitors the discharge plans and arrangements for assigned patients.
4. Works with patients and their families to help them understand the impact their illness may have on their lifestyle, family, relationships and home situation.
5. Coordinates individual patient care conferences when deemed necessary, including appropriate inpatient and outpatient personnel/agencies.
6. Develops a discharge plan in a timely manner to maintain lowest cost to the hospital, while ensuring a comprehensive quality plan.
7. Procures signature on second Medicare Important Message (IMM) form for assigned patients as required by CMS 48 hours prior to discharge.
1. Records all patient/family activity, interaction or intervention related to discharge planning in the electronic medical record.
2. Documents action taken related to discharge planning within same day of interaction with patient/family and/or physician.
3. Accurately records payor information related to review, level of reimbursement and appeal decision in the electronic medical record.in the electronic medical record.
4. Documents Physician Advisor and EHR referrals in the electronic medical record.
Education Training and Experience
• Past experience in a leadership role preferred.
• Minimum of three years of acute clinical experience in the designated specialty.
• Prior utilization management and/or discharge planning or relevant experience is a plus.
• Knowledge of Inter Qual Acute Care Criteria
• Must have demonstrated excellent communication skills with proven ability to negotiate and collaborate with others.
• Ability to be flexible, organize, prioritize and remain calm in stressful situations.
• Understands the complexity of the health care system and is able to apply theory with practice.
• Must have good computer skills.
A Pennsylvania licensed Registered Nurse and BSN with Case Management experience
Case Management Certification preferred
We are an Equal Opportunity and Affirmative Action employer. Candidates are considered for employment without regard to race, ethnicity, color, sex, sexual orientation, gender identity, religion, national origin, ancestry, age, disability, marital status, familial status, genetic information, domestic or sexual violence victim status, citizenship status, military status, status as a protected veteran or any other status protected by applicable law.