- Coordinates the integration of social services/case management functions into the patient care, discharge, and home planning processes with other hospital departments, external service organizations, agencies, healthcare facilities and community resources.
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- Facilitates Medical Necessity Determinations, regarding admissions or continued stays, extended stay, professional services.
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- Ensures patient is in the appropriate “Status” and appropriate “Level of Care”; seeks out Secondary Physician Review when warranted. Assesses Emergency Room patients for Observation or Inpatient status as applicable, minimally every four (4) hours.
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- Conducts concurrent medical record review using specific indicators and criteria as approved by medical staff, The Joint Commission, CMS, and other state agencies.
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- Manages Payer Interface, real-Time Denial Management, including sending applicable clinical information to Payers (via NaviHealth).
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- Ensure timely payer notification and communication to support admission, clinical condition, continued stay, authorization of post-acute services.
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- Acts as a patient advocate: investigates and reports adverse occurrences, and performs staff education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.
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- Promotes effective and efficient utilization of clinical resources. Manages Length of Stay (LOS), including avoidable delays and days, and participates in long LOS rounds.
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- Mobilizes resources and interviews, as needed, to achieve expected goal(s) to assist in achieving desired clinical outcomes within the desired timeframe.
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- Manages sequencing, to ensure consults, tests and procedures ae sequenced appropriately and supports timely and efficient delivery of care.
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- Conducts review for appropriate utilization of services from admission through discharge. Evaluates patient satisfaction and quality of care provided.
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- Assesses patient care required throughout continuum of care for diagnosis, procedures and DRG’s.
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- Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assist physicians to maintain appropriate cost, case, and optimal patient outcomes.
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- Completes Initial Case Management Assessment and Reassessment on patients, including expanded assessment of patients and family needs at time of admission. Completes psychosocial assessment as applicable.
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- Screens/identifies clinical, psychosocial, financial, operational factors affecting progression of care.
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- Assess patient’s progress through expected hospital course.
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- Assesses and identifies patients with post-acute needs, including Readmission Avoidance.
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- Medical/Clinical Discharge Planning, hand-off post-acute placement to Social Worker.
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- Refers cases where patients and/or family would benefit from counseling required to complete complex discharge plan to social work.
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- Establishes Discharge Plan at admission and continually reevaluate, triggers referral to Social Worker (hand-off).
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- Serve as a patient advocate. Enhances a collaborative relationship to maximize the patient’s and family’s ability to make informed decisions.
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- Facilitates interdisciplinary/multidisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family education and identified post-hospital needs, as well as address discharge barriers early.
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- Collaborate with clinical staff in the development and execution of the plan of care and discharge plan including the achievement of goals. Ensure Plan of Care and discharge plan clinically appropriate and consistent with patient choice and available resources.
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- Directs and participates in the development and implementation of patient care policies and protocols in order to provide advice and guidance in handling special cases or patient needs.
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