The case manager plans, coordinates, develops, evaluates, and monitors the care of assigned group of patients to achieve quality cost effective patient outcomes. Completes a discharge assessment on all assigned patients. Completes screening tool as indicated. Meets with all new admissions to assess and discuss a proposed discharge plan and follow the progress of the discharge plan until discharged. 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. Set-up post discharge services such as home health, dual medical equipment, returns back to nursing home, swing bed, etc. Attends daily care management team meetings. Assigns working DRG length of stay on all new inpatient admissions. Demonstrates knowledge and skills to appropriately communicate and interact with the patients, families, and visitors while being sensitive to their cultural and religious beliefs.Provides assistance to ensure placement of patients in the most appropriate care setting. 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. Issues hospital notices as indicated such as Important Messages from Medicare, Medicare Outpatient Observation Notices (MOON) and Hospital Issued Notice of Non-Coverage (HINN). Reviews scheduled Medicare outpatient surgeries for compliance with the APC “Inpatient Only” listing. Collaborates with physician advisors, attending physician or chief medical officer for questioned admissions to ensure set guidelines are followed for issued notices or an appeal. Evaluates the use of observation bed services to ensure that patients are either admitted to a higher level of care or discharged in a timely fashion to avoid potential loss of reimbursement. For those patients at risk for readmission, the case manager will apply interventions to proactively prevent a readmission, and identify the cause(s) for those who readmit to avoid for further readmission, when applicable. Is involved in utilization review activities as defined by utilization management process. Obtains authorization from third party payers timely as indicated. Consistently follow-up and update authorization/certification information on an ongoing bases. Track denials and appeals, document them on a consistent bases, and then refer to denial management coordinator as indicated. 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 task as needed. Assembles, analyzes, monitors, and tracks data for reporting as designated by the Director.
Performance Expectation:
- Accomplishes work in ways that maximize productivity.
- Responds positively to and have to aptitude to deal with multiple task
- Demonstrate the ability to manage daily workload.
- Adheres to various regulatory guidelines.
- Demonstrate the ability to learn and follow various regulatory guidelines.
- Demonstrates practices of all establish patient safety and infection control intervention.
Qualifications:
Education/Skills
Degree from an accredited, non-online RN program, preferred. Associate or Bachelor of
Science in Nursing required.
Work Experience:
Three or more years of experience in clinical nursing required. 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:
Exceptional oral and written skills are required to relate effectively to hospital staff, physicians, physician office staff, and review agencies. The individual must have the ability to type and be familiar with the rules of spelling, grammar, and punctuation. The individual must have the ability to use a copier, telephone, and personal computer. Workable knowledge of DNV standards and other regulatory systems is essential. Workable knowledge of correct coding procedures, InterQual criteria, Milliman Care Guidelines (MCG), Perspective Payment System and medical terminology is necessary. The individual must have a high energy level and be capable of handling pressure situations both mentally and physically.
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