Collaborate with the health care team to assess, plan, implement, monitor and evaluate options and services to enable the progression of patients across the care continuum.

ESSENTIAL JOB FUNCTIONS

Qssentials

Demonstrates the use of the AIDET communication method towards customers. Exceeds expectations by following our Standards of Behavior:

Comply with organization, department and regulatory standards.

Follow policies, procedures and standards.

Participate in staff meetings/activities/inservices.

Accept instructions, guidance and corrections and modify behavior accordingly.

Demonstrate support for all Vista strategic initiatives and resulting operational changes.

Self-appraisal to determine progress in meeting performance objectives & career goals.

Attend work as scheduled.

Utilize the appropriate chain of command and channels of communication.

Update knowledge to reflect current professional practices by attending seminars, meetings and reading current literature.

Participate in opportunities/activities to enrich job knowledge & performance.

Complete annual dept & organization education & competencies in a timely manner.

Coordinate the case management process

• Demonstrate the knowledge and skills necessary to provide care/service appropriate to the age of patients/customers served.
• Demonstrate knowledge of the principles of growth and development over the life span. Assess data reflective of the patient/customer’s status and interpret the appropriate information needed to identify each patient/customer’s requirements relative to his/her specific needs.
• Provide care/service needed as described in the department’s policies/procedures
• In collaboration with the patient, family and multidisciplinary team (including physicians and payers), perform clinical assessments to ensure the patient’s progress through the acute episode and after discharge as indicated in an efficient and cost effective manner:
  1. Intervene with physicians to influence timely and effective orders to expedite care.
  2. Intervene with diagnostic services to avoid delays in service.
  3. Identify barriers and suggest interventions in treatment plan.
  4. Lead patient care conferences as indicated to resolve barriers.
  5. Coordinate plan of care with the multidisciplinary team to ensure all critical elements have been communicated to the patient/family and all members of the team.
• Facilitate implementation of a timely case management plan and update the plan in collaboration with the multidisciplinary team in accordance with patient clinical course and continuing care needs to expedite post-discharge care.
• Analyze case management outcome data to identify and make recommendations within a designated service line.
• Consult with Medical Advisor(s) as necessary to overcome identified discharge barriers.
• Use quality screens to identify potential issues & forward information to Quality Mgnt.

Coordinate the discharge planning process

• Utilize high risk screening criteria to initiate the case management planning process as mandated by the CMS.
• Refer to social worker when case manager assessment identifies patients/families with complex physical, psychosocial, environmental and/or financial discharge planning issues.
• Initiate and facilitate referrals for home health, hospice DME, community services, etc. Facilitate patient movement to appropriate level of care through collaboration with patient, family, physician, multidisciplinary team and third party payers.
• Identify and utilize community resources.
• Serve as a liaison to post-hospital care providers and community health resources.

Perform utilization review duties

• Using approved criteria, conduct admission reviews of patient admission or observation stay to ensure the appropriateness of the setting and communicate appropriately with the physician.
• Using Interqual level of care criteria, conduct continued stay review and monitor the patient’s progress through the acute care process and along the continuum of care. Intervene as necessary to ensure the appropriateness of the setting and efficient, effective services.
• Coordinate to ensure third party payer precertification and/or recertification as required and advise patient and physicians of same. Intervene to avoid concurrent denial of services by planning care and discharge needs with the attending physician, Medical Advisor, Case Management Director and the health care team.

Support PHIP

• Communicate with assigned coder.
• Prompt physicians as necessary to provide requested documentation

Maintain documentation

• Document all review data as appropriate.
• Demonstrate knowledge of computer programs necessary to facilitate complete documentation.
• Document discharge screen in Optimum iMed within 24 hour as appropriate. Discharge Notes to be updated as needed to reflect the discharge plan.
• Utilization information, including contacts with payers to be documented in AS-400

Provide information regarding denials and approvals

• Provide information to appropriate liaison regarding denials and approvals.
• As appropriate, work with third party payers and develop case for the purpose of overturning denials for reimbursement.

Provide education to patients, physicians, multidisciplinary team & the community

• Provide information and support to patients/families regarding discharge level of care, referrals and transition to the continuum as indicated.
• Participate in multidisciplinary educational programs for health professionals and the community as appropriate.
• Act as mentor and resource person in the development of new case management staff.

Perform all other duties as assigned

• Perform other duties relevant to case manager functions to support and foster an effective care management program as assigned by director or designee.
• Perform all tasks in a safe and approved manner to avoid injury to self and others.
• Complete projects in a timely and professional manner.
• Maintain confidentiality of all information.
• Be receptive and adaptive to change.

SUPERVISION EXERCISED

Works with minimal supervision.