Overview

The Case Manager will coordinate care using a collaborative approach with the multidisciplinary team in identifying the required services needed to meet an individual’s health needs while hospitalized. The UCMRN will be expected to identify, intervene and expedite issues which many adversely affect the length of stay and quality of care by communicating and using all available resources.

Posting internally from 10/10-10/25

Responsibilities

- Establish and maintain positive relationships with patients, visitors, and other employees. Interacts professionally, courteously, and appropriately with patients, visitors and other employees. Behaves in a manner consistent with maintaining and furthering a positive public perception of Bronx-Lebanon Hospital Center and its employees.

- Contributes to and participates in the Performance/Quality Improvement activities of the assigned department. Contribution and participation includes data collection, analysis, implementation of and compliance with risk management and claims activities, support of and participation in Continuous Quality Improvement (CQI) teams, consistent adherence to the specific rules and regulations of the Bronx-Lebanon Hospital Center (a) Safety and Security Policies, (b) Risk Management: Incident and Occurrence Reporting, (c) Infection Control Policies and Procedures and (d) Patient and Customer Service.

- Develop an individualized case management plan to assure appropriate and timely utilization of hospital, community based and other resources for optimal, cost effective discharge planning.

- Conduct patient and family assessment for all admissions to assigned unit utilizing approved criteria, critical pathways and established algorithms within 24 hours of admission. The UCMRN will assure appropriateness for acute care and medical necessity in order to achieve certification status and insure reimbursement to the hospital.

- Identify risk factors (i.e. actual and potential adverse days, denied days, adequacy of LOS based on acuity). Intervene with appropriate party to resolve and/or prevent delays and optimize a smooth transition through all levels of care.

- Maintain knowledge of Managed Care requirements, DRG, insurance benefits, IPRO regulations and nationally recognized medical necessity criteria.

- Coordinate interdisciplinary discharge planning team conferences in order to monitor appropriateness of the discharge plan by coordinating community resources and other offsite services to ensure continuity of care post discharge.

- Frequent interaction with attending physician(s) in order to facilitate the timeliness in rendering quality patient care and the development of further individualized case management plans.

- Participate in interdisciplinary unit rounds and serve as a resource person for Nursing, Ancillary and Medical staff.

- Conducts screening and case findings in cooperation with other health care professionals. Preparation of Patient Review Instrument (PRI) Screen, Case form, AIDS chronic care package required. Involve patient and/or family regarding placement plans and document same.

- Coordinate and facilitate services rendered and resource utilization for cases managed to improve the efficiency and delivery of patient care via integration of the total quality management process.

- Identify and report problematic cases with extended LOS providing updated information to Utilization Case Manager and /or Director for further action. Identify quality concerns utilizing quality improvement screen indicating action taken by UCMRN and identify party conferred with. Complete Nursing Home discharge list and managed care Potential Adverse Determination (PAD) list to UCMRN weekly.

- Enter data related to admission, continued stay and discharge planning into the 3M HDM system via the laptop or PC’s.

- Conducts focus studies for the purpose of trending, benchmarking and improving care rendered and practice patterns as required.

- Acts as patient advocate.

- Dialogues with home care liaison practitioner or managed care organization. Follows up telephonically to ensure compliance with continued outpatient treatment, medical regimen and changes on after care needs and continued coordination of services.

Qualifications

BSN, Current NYS license to practice as a Registered Professional Nurse.

Successful completion of Commission for Case Management Certification (CCMC) within three (3) years of hire, if not currently certified.

Minimum three (3) years of clinical experience in Nursing, preferably in Case Management.

Experience with InterQual and Milliman Care Guidelines.

Knowledge of DRG and GMLOS, Managed Care and Regulatory Requirements preferred. Knowledge of Regulatory Guidelines governing hospitals, Medicare, Medicaid, Island Peer Review Organization (PRO), and other Third Party criteria and standards as applicable.