Overview

The Care Manager is an administrative staff assigned position responsible and accountable for patient outcomes as related to coordination of patient management through the continuum of care. Responsible for financial, clinical, and discharge planning evaluation for each assigned patient. Ensures payment for services rendered, coordinates care, manages appropriate consumption of resources, and facilitates each patient encounter for efficient and effective outcomes as related to quality, clinical and cost areas.

Responsibilities

The Care Manager licensed nurse manages a caseload of patients that may be covered by various payers. Cases are managed from preadmission to discharge to ensure appropriate level of care based on appropriate screening criteria and regulatory criteria in various stages of the process based on tier of job assigned.Assumes responsibility for patient encounter appropriateness, (outpatient, observation, inpatient admission), continued stay, and documentation monitoring to ensure meets regulation and standards. Coordinates communication with third party payers, external review agencies and the Outcomes Management Committee.Identifies managed care issues and address promptly as related to denials management Monitors and analyzes denials monthly and reports cause analysis to director.

Coordinates and collaborate with physicians, other providers and healthcare practitioners’ multidisciplinary team and other health care professionals concerning patient’s goals, plan of care and progress to ensure timely and appropriate management of care and ensure financial effectiveness of care.

Revise and adjust on a daily basis the plan of care to accommodate the needs of the individual patient based on continuing assessment of patient condition.Care Manager I leads discharge planning multidisciplinary team meetings, ensures documentation of meetings to meet accreditation and regulatory standards.

Advocate for the patient/family, is knowledgeable of, and act in accordance with legal principles of consent, healthcare proxies (power of attorney for healthcare) and advance medical directives.

Stays abreast of developments in the case management field and seeks ongoing education to enhance practice skills. Care Management is willing to seek certification in case management field if made available through ARH.

Stays abreast of regulatory agency guidelines as pertains to area of practiceInitiate and monitor clinical care guidelines and analyze positive and negative variancesEnsure continuity of care through assisting with formulation of discharge plan on admission and follow though until patient is discharged.Ensures that patients stay is appropriate based on screening for medical necessity. Works with medical staff, hospital staff, and others to overcome barriers to discharge.

Participates in the denials management process to help ensure establishment of and adherence to processes that will minimize denials by third-party payers.

Participates as a member of the Outcomes Management CommitteeAssists in the collection of data to trend and analyze outcomes for identification of improvement opportunities.

Maintains knowledge of applicable JCAHO standards and other regulatory agency requirements and works with leaders within the organization to maintain ongoing compliance.

Participates in data collection, specific to outcomes data.

Assesses the appropriateness of the level of care; diagnostic testing and clinical procedures; quality and clinical risk issues; and documentation of medical record completeness.

Performs other related duties as assigned.

Qualifications

EDUCATION, TRAINING, AND EXPERIENCE:

Care Manager INurse (licensed in state of employment) from an accredited school for nursing and a minimum of five years nursing/clinical experience or licensed nurse with certification in the case manager or associated field.Care Manager IIBachelor’s degree in nursing preferred or certification in the case manager or associated field. Registered nurse with 5 Years of nursing experience may be considered with demonstration of skills required for the position.

Demonstrated ability to analyze, synthesize, report and manage patient care data obtained through previous experience in outcomes management activities.

Demonstrated written and verbal communication skills. Proficient in use of computer with good working knowledge of use of Microsoft office and McKesson STAR recommended.

POSITION PHYSICAL REQUIREMENTS:Must possess the physical ability needed to exert 20 to 30 pounds of force occasionally; and/or 10 to 20 pounds of force frequently; and/or greater than negligible up to 10 pounds of force constantly to move objects. Physical Demand requirements are in excess of those for light work.