Case Manager

Case Managers function as the non-physician team leader and as such assumes overall responsibility for coordinating services, programs and personnel necessary to maximize patient outcomes and quality care, ensuring efficient movement of the patient through the continuum of care, and minimizing unnecessary resource utilization.

Job Description:

· Case Management is a comprehensive, coordinated approach to planning high quality patient care for all patients from the neonate, infant, pediatric, adolescent, adult and geriatric population (s). Case Managers function as the non-physician team leader and as such assume overall responsibility for coordinating services, programs and personnel necessary to maximize patient outcomes and quality care, ensuring efficient movement of the patient through the continuum of care, and minimizing unnecessary resource utilization. In order to perform this function, the Case Manager must have exceptional clinical assessment and intervention skills in order to oversee the care provided their patient population. The Case Manager must review the patient’s status daily and identify issues requiring intervention. They must anticipate, plan and discuss patient needs with the patient and family, physician, members of the interdisciplinary team, and third party payers’.

· As the non-physician team leader, the Case Manager must ensure appropriateness and timeliness of medical interventions and ancillary services. They are to ensure a collaborative and team approach to patient care in order to minimize delays in care delivery and ensure positive outcomes. As such, the Case Manager oversees the collection of appropriate data that identifies opportunities for improvement in service delivery and assists in improving the efficiency and effectiveness of services when appropriate. The Case Manager must work closely with physicians and intervene when barriers to care are encountered. In addition, the Case Manager will oversee clinical documentation to ensure documentation is complete and accurately reflects the patient’s status and medical interventions completed.

· The Case Manager is responsible for ensuring ongoing communication and collaboration with payor sources, achieving appropriate pre-certification and ongoing concurrent certification such that Teton Valley Health Care (TVHC) is paid appropriately for services provided. As such, the Case Manager must have an in-depth knowledge and ability to apply various payers rules and regulations, admission, discharge and continued stay reimbursement criteria and the Interquel Care Guidelines. The Case Manager must ensure that patients are admitted appropriately, and that continued care is appropriate for their clinical needs in the appropriate place in the continuum. While the Case Manager must monitor resource management and cost effectiveness of care for their patient population; patient safety and achieving positive clinical outcomes will always be the ultimate guiding force in the Case Managers position.

· As part of this role, the Case Manager must also oversee the discharge planning process including plan development, implementation, education and acquisition of resources for a successful discharge. The Case Manager oversees utilization of patient care protocols and ensures appropriate patient and family education has occurred prior to discharge.

· Personal characteristics include cooperation, flexibility, imagination and resourcefulness. The Case Manager must have strong initiative, excellent judgment, good problem solving skills, and excellent interpersonal skills. The Case Manager also must have very strong clinical skills in their assigned area. They must be able to influence others without direct authority over them, and have strong conflict resolution skills and acumen in dealing with difficult people.

· The Case Manager is expected to practice autonomously within the scope of professional standards, the rules and regulations established by the Idaho Board of Nursing, and knowledge of the policies and procedures within TVHC. He/she has a working knowledge of the nursing process and demonstrates skill in developing and guiding collaborative collegial practice that delivers safe competent care. He/she demonstrates sensitivity and understanding of the diverse cultural backgrounds of our patients and caregivers. The position involves maintaining current knowledge of evidence based nursing practice and the ability to demonstrate critical thinking skills in the implementation of all phases of the nursing process. He/she actively participates in continuous quality/performance improvement of patient care through data collection, as well as, interpreting/evaluating the data and planning actions. The Case Manager serves as a professional role model as a caregiver, mentor, teacher and resource for peers and other providers. He/she demonstrates competency in the care of the neonate, infant, and child, adolescent, adult, and geriatric patient.

· Implement discharge plan on each patient near time of admission, follow through as needed, and contact resources as appropriate.

· Facilitates Interdisciplinary Care plan and discharge planning meeting.

· Admission review to conform to requirements of PRO and insurances.

· Concurrent review as indicated, maintain liaison with family members and physician as necessary.

· Emergency / Urgent care admission follow-up.

· Indigent care consultation and referral.

· Insurance Contact on extended stays.

· Coordinate swing bed admissions

· Educates the organization and the clinicians regarding regulatory changes as they relate to utilization review, status changes, and resource availability for patients