Overview

 

Monitors patient care progress toward goals, makes recommendations and/or utilizes appropriate resources to optimize effective, efficient care progression and care plan goal achievement. Coordinates care transition from inpatient to next level of care. Performs admission and continued stay utilization reviews and discharge screening to assure the necessity of hospital admission, appropriate level of care, continued stay and supportive services, appropriate safe discharge/transition plan, and to examine delays in the provision of services. Collaborates with attending Physicians, Mid-level Providers or Department Medical Directors concerning status and/or medical necessity issues. When criteria is in question, escalates care for second level Physician review when Department Director is unavailable.

Talent Pool: Nursing 

Responsibilities

 Performs case assessment and evaluation. Proactively conducts initial case review within 24-48 hours of admission for all inpatients utilizing criteria accepted by Cone Health as set form in the department's Utilization Management Plan. Subsequent reviews will be conducted every three days as long as the patient remains in the hospital to comply with all State and Federal rules and regulations. Review all patients' in observation status daily to assess need for continued observation, discharge or conversion to inpatient. All reviews will be documented in Midas and sent to appropriate Care Management Assistant for processing to insurance companies immediately upon completion of all inpatient reviews, and abservcation cases as requested by the payor.--------------------------------------------------Coordinates care planning and progression. Collaborates with healthcare team members, including medical team to formulate individualized plan of care and discharge plan. Initiates implementation of discharge plan upon initial assessment and coordinates changes to this plan with healthcare team members on an ongoing basis. Consistently and accurately documents plan in medical record and updates documentation as plans are revised. Identifies patients/families with complex psychosocial needs/issues and refers those cases to Clinical Social Work for follow up in a timely manner.--------------------------------------------------Ensures collaboration of healthcare team. Communicates collaboratively on a routine basis at Care Progression meetings, during unit/team rounds and throughout the day with the healthcare team members to ensure patient care needs are addressed. Routinely refers appropriate issues/cases to Department's Physician Advisor in a timely manner. Communicates effectively with peers to assure that patient needs are met, including hadnoffs and staff covering care. Consistent communication with department leadership is an expectation.--------------------------------------------------Provides oversight of utilization of resources. Accurately identifies issues surrounding the appropriate utilization of resources and provides follow up corrective action in a timely namner in collaboration with appropriate healthcare team members. Provides immediate, on-going education of healthcare team members on such issues as payer requirements, denials, avoidable delays/variances, regulatory agency regulations, compliance, post-acute provider referral processes and other appropriate alternative care options. --------------------------------------------------Provides documentation of case management processes. Supports other department and healthcare team members in providing appropriate services and effective care by supplying comprehensive documentation in department and Cone Health electronic systems and medical record as required by policy. Consistently and accurately documents plan in medical record and updates documentation as plans are revised. Provides comprehensive information to weekend staff to assist them in providing effective follow up and continuity of care. Routinely identifies avoidable days/variances and documents these in the department's electronic system prior to discharge.--------------------------------------------------

Qualifications

EDUCATION:Bachelors, Nursing, requiredMasters, Healthcare Related Field, preferredEXPERIENCE:- 3-5 years of recent related acute care experience required.- 1-2 years of Case Management and/or Utilization Review experience preferred.LICENSURE/CERTIFICATION/REGISTRY/LISTING:REQUIREDRN | Registered Nurse licensed in North Carolina or a Compact state.- Current North Carolina Registered Nurse license required.- CPR is required for Case Managers at Behavioral Health locations and is preferred at all other locations.PREFERRED- Current Case Management certification of CCM or ACM preferred.- CPR is required for Case Managers at Behavioral Health locations and is preferred at all other locations.