Job Description
POSITION PURPOSE:
The purpose of this Case Manger role is to provide inpatient care coordination and concurrent review services for identified hospitalized medical / surgical patients HealthPartners members to facilitate optimal patient outcomes, improve continuity of care and maintain cost effectiveness over an episode of care. He or she will collaborate with the Attending Physician, Specialist and/or hospital staff to ensure that an effective and timely treatment plan is acted upon; an appropriate discharge plan is implemented with smooth transitions in levels of care.
ACCOUNTABILITIES:
Provide on-site and/or telephonic inpatient case management and concurrent review for identified hospitalized medical / surgical HealthPartners members.
Monitor medical necessity, appropriateness and efficiency of care using established inpatient guidelines, contacting Supervisor, Physician, Specialist, Hospitalist, and Medical Director as needed.
Participate in discussion of delays / barriers / progression of care at care coordination rounds or in 1:1 meetings with physicians, specialists and/or hospital staff.
Consistently apply HealthPartners organizational and department values (Mission / Vision / Initiatives) and continuous quality improvement in their daily work.
Be knowledgeable of patient's available benefits / coverage / payor information.
Be knowledgeable of community programs and resources available to patients within their benefit plan.
Prioritize daily workload to ensure efficiency in completing daily work (patient discharge needs are met, guidelines are followed with proactive discussion of delays / barriers to efficient care, data entry is completed).
Facilitate communication between patient, family, physician, social services, and vendors to maintain continuity of care and appropriate use of resources.
Serve as a resource to patients, providers, and internal departments. Facilitate and comply with application of benefits processes as needed in close coordination with medical director and care team. Perform utilization management for HealthPartners members admitted to Out of Network Facilities, acute rehabilitation facilities, facilitating the approval/denial of services provided.
Coordinating transfer of patient to in network facilities when appropriate.
Assist in monitoring of annual financial goals for inpatient case management LOS, readmission's, and denial rates, cost savings, patient/provider satisfaction and achievement of outcomes.
Remain current with knowledge and skills of case management and utilization management practices, application of guidelines, policies and procedures related to case management.
Remain current with knowledge to ensure compliance with government programs such as Medicare / Medicaid requirements and regulations.
Maintain confidentiality of information obtained in performance of duties as well as HealthPartners policies & procedures.
Discuss cases not meeting medical criteria and cases with utilization issues with physician, social worker, other care team members and medical director as needed.
Assist in monitoring of annual goals for case management LOS, referrals, readmissions, denial rates, cost savings, patient/provider satisfaction and achievement of outcomes.
Serve as a liaison to other agencies, departments, or community resources as needed to coordinate care in transition planning.
Participate in required educational programs and actively demonstrate self-directed learning and continuing education to enhance professional development in the area of case management.
Participate in staff development activities and staff meetings.
Identify and refer to manager and supervisor all cases involving potential high cost, sensitive or complex medical issues for review.
Record, monitor and report data such as clinical outcomes achieved, potentially avoidable and medically necessary variances, denials, length of stay, reviews completed and outcomes (savings and referrals), and discharge dispositions on a daily basis.
Work with the attending physician, hospitalists/rounders, specialists, hospital and social work staff to create an actionable plan of care and transition / discharge plan for each patient followed, as needed.
Demonstrate knowledge regarding transition criteria and level of care and use of appropriate community-based resources.
Review and assesses inpatient cases for eligibility, benefits and limits, medical necessity and ongoing appropriate level of care.
Function independently and as part of a team, working effectively with various departments, internal and external staff, facilities, patients, patients' family, and physicians to facilitate quality and efficient patient care.
Provide services at sites throughout the metro area on an as needed basis, based on assignment / census.
Perform other duties as assigned.
REQUIRED QUALIFICATIONS:
Registered Nurse with current unrestricted license in the State of Minnesota, BSN preferred. License free of history of restrictions and/or sanctions in the past 10 years in all states with current or past licensure.
Minimum 3 years experience as a Registered Nurse in a clinical setting, performing utilization review, case management or discharge planning
Excellent verbal, written and interpersonal skills
Excellent problem identification and problem solving skills and follow through skills
Excellent organizational skills and ability to prioritize workload
Function independently and as part of a team, working effectively with various facilities, internal and external staff, patients, patients' family, and physicians to facilitate patient care
Able to work with individuals of diverse back grounds
Ability to deal with change and ambiguous situations
Basic computer skills
PREFERRED QUALIFICATIONS:
Bachelor of Science or Arts degree in nursing from an accredited college or university
Experience with utilization review criteria
Public health or home care experience
Understanding of managed care and case management concepts
Basic understanding of healthcare economics and consumerism within healthcare
Certification as a CCM, CMC or equivalent case management certification