Job Title: Case Manager/RN/8hrs.

Base Rate: $46.07 - $64.51

Job Summary: The Case Manager is responsible for managing and coordinating the care of the patients in the acute care setting. Analyzes patient’s records to determine legitimacy of admission, treatment, and length of stay in health care facility to comply with government and insurance company reimbursement policies by performing the following duties personally or through subordinate supervisors. Participates in the establishment and implementation of the hospital and Departmental Services philosophy, objectives, policies and procedures. Actively and consistently contributes to department operations and communications, behaves in a manner consistent with the mission, vision, and values of Pipeline Health, upholding standards of AIDET (Acknowledge, Introduce, Duration, Explanation, Thank you) patient communication.

Essential Functions:

• Determine legitimacy of admission, treatment, and length of stay in health care facility to comply with government and insurance companies.
• Establish criteria and confer with medical and nursing personnel and other professional staff to determine appropriate level of care, utilization of resources, length of stay and quality of care.
• Assess financial classifications and status and make appropriate referrals as needed.
• Abstract data from records and maintain statistics.
• Assumes role of patient advocate respecting Patient’s Rights.
• Analyzes insurance, governmental, and accrediting agency standards to determine criteria concerning admissions, treatment, and lengths of stay of patients.
• Ensures that the patients are properly and efficiently admitted within the hospital guidelines and assists the staff in handling difficult or problem admissions.
• Assist in the maintenance of Medicare log, Medi-cal log, department statistics, and utilization review documents according to department policy and procedures and existing laws of the State and Federal Government.
• Serves as liaison or contact person to agencies having insurance payment contracts. Review and recommend changes relative to Utilization Review for all proposed insurance contracts, is primary contact person for the Medicare/Medi-Cal program.
• Reviews records for services provided to patients to assure the accurate selection of the principal diagnostic codes, procedures and pre-existing conditions in accordance with contractual agreements.
• Appropriately communicates with family and health professionals.\
• Evaluate criteria and length of stay for appropriateness utilizing Milliman and Robertson criteria to coordinate care plan with physician and/or physician advisor.
• Works with Social Worker regarding discharge planning
• Manage resource utilization to ensure appropriate level of care, manage length of stay, evaluate cost effectiveness of care plan and mange utilization of ancillary services.
• Report QI, Risk and patient care issues to appropriate departments.
• Support Case Coordinator whenever days are questioned or denied by managed care plan.
• Identify and track patients for “10 Transfer DRG’s”, insuring appropriate level of care and length of stay.
• Covers Nursing Units as needed for Sick Calls and PPT
• Uses clear, concise, professional communication with coworkers, patients, all customers internal and external.
• Uses AIDET in interactions with patients and family members. Utilizes white boards for patient communication.
• Collaborates across disciplines to assist in coordination of patient care, including but not limited to patient transfer, discharge, referrals, and spiritual/psychosocial support needs.
• Acts with a sense of urgency when performing tasks.
• Basic unit/department maintenance such as keeping files, drawers, cabinets free from unnecessary clutter. Reports on any equipment and or environmental issues for repair.
• Abides by HIPAA (Health Insurance Portability and Accountability Act) regulations.
• Utilizes SBAR (Situation, Background, Assessment, Recommendation) when communicating with oncoming shift, physician communication and giving report to ancillary or other nursing services.
• Speaks up to stop the line and escalates potential safety events if necessary.
• Completes and attends monthly training assigned.
• May float to other areas of the hospital as needed.
• Other duties as assigned.

Experience:

• Minimum one (1) years’ experience in case management in an acute care setting.
• Critical thinking, service excellence and good interpersonal communication skills, ability to read/comprehend written instructions, strong organizational skills, ability to follow verbal instructions, and PC (computer) skills.
• A capacity to learn, synthesize, make critical judgments, work independently, place patients and families first, and collaborate with the team members who are recognized leaders within health care.

Licenses/Certifications:

• Current professional RN license issued and/or recognized by the state Board of Nursing for the State of employment.
• Basic Life Support (BLS) from American Heart Association (AHA) required.
• Accredited Case Manager (ACM) or Certified Case Manager (CCM) a plus.