CASE MANAGER

Job Summary:

• The hospital case manager coordinates patient care, ensuring a smooth transition through the hospital stay and beyond. They assess patient needs, develop care plans, and facilitate communication between patients, families, and the healthcare team. Case managers also play a key role in discharge planning and utilization review, helping patients access appropriate resources and services.

Essential Functions:

• The case manager plans, coordinates, develops, evaluates, and monitors the care of assigned group of patients to achieve quality cost-effective patient outcomes.
• Completes & documents in the EMR, a discharge assessment on all assigned patients, which would include meeting with all new admissions to assess and discuss a proposed discharge plan and follow the progress of the discharge plan until discharged.
• The Case Manager in the discharge planning role, will attend daily care management team meetings on their assigned unit.
• Works collaboratively with interdisciplinary teams to identify services required to meet the patient and family needs throughout the continuum of care, while ensuring that appropriate resources are implemented in a timely manner.
• Identifies and arranges appropriate post discharge services such as Home Health Care (HHC), Hospice, Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Long Term Acute Care Hospital (LTACH); Durable Medical Equipment (DME), or returns back to nursing home.
• Communicates in a timely manner with the appropriate payer to initiate authorization for identified post-hospital services.
• Demonstrates knowledge and skills to appropriately communicate and interact with the patients, families, and visitors while being sensitive to their cultural and religious beliefs.
• Collaborates with physician, physician’s office staff and registration staff and obtain the necessary information to support medical necessity and the medical review policies to assist in validating appropriateness of admission, services, and continued stay and, if necessary, issue letters of non-coverage as indicated.
• Collaborates with registration staff and physician’s office staff regarding physician orders for correct patient status assignment (Inpatient or Observation).
• Issues Medicare hospital notices as indicated.
• Collaborates with physician advisors, attending physician for questioned admissions to ensure set guidelines are followed for issued notices or an appeal of discharge.

• For those patients at risk for readmission, the case manager will to identify and address the cause(s) for readmission to avoid for further readmission, when applicable.
• The Case Manager in the Utilization Management (UM) role is involved in utilization review activities as defined by utilization management process.
• The UM Case Manager performs admission reviews to ensure that assigned patients meet identified clinical criteria and are assigned to the correct admission status (Inpatient or Observation) and the UM nurse continues to monitor this throughout the hospital stay.
• Performs timely level of care reviews on assigned patients and provides clinical updates to third-party payers in a timely fashion and obtains authorization from third party payers as indicated.
• Consistently follow-up and update authorization/certification information on an ongoing basis.
• The Case Manager will record, report and document denials and appeals on their assigned assigned group of patients and will follow-up with physician advisor and Denial Coordinator or other designated staff.
• Functions as the central liaison between the Medicare QIO, review agencies, Business Services, Patient Financial Services, and other healthcare professionals affected by concurrent review, DRG assignment, the certification process, and discharge planning.
• Is involved in utilization review activities as defined by the utilization management process. Participates on various committees/ task forces as needed.
• Assists team leader with training of new staff or other tasks as needed. Assembles, analyzes, monitors, and tracks data for reporting as designated by the Director.

Performance Expectation:

• Responds positively to change and has the ability to deal with multiple tasks
• Accomplishes work in ways that maximize productivity.
• Demonstrates the ability to manage daily workload.
• Interacts effectively and builds respectful relationships with internal and external customers.
• Adheres to various regulatory guidelines.
• Advocates for and positively represent case management initiatives when working with others.
• Demonstrate the ability to learn and follow various regulatory guidelines.
• Demonstrates practices of all establish patient safety and infection control intervention.
• Follows facility policies and procedures as they apply

Qualifications:

Education/Skills

• Graduate from an accredited, non-online RN program required.
• Bachelor of Science in Nursing preferred.

Work Experience:

• One to three years of experience in clinical nursing required.
• One to three years Case Management and/or Utilization Management experience preferred.

Certification/Licensure-DUE UPON HIRE

• Licensed RN able to practice within the State of MS

Mental Demands:

The successful candidate will be able to write and communicate professionally. The incumbent will be proficient in medical terminology, computer skills and use of basic office equipment such as copier and fax machine. The individual must have good time management skills and the ability to manage multiple tasks.

The successful candidate should have an understanding of the following:

• Clinical screening criteria, such as InterQual and Milliman Care Guidelines (MCG)

• Medicare’s Prospective Payment System (PPS) & Outpatient Payment System (OPPS)

• Medicaid and other third-party payer general guidelines