Registered Nurse - Case Manager 9A-9P

JOB SUMMARY

Interacts directly with patients, caregivers, and all members of the healthcare team to perform essential case management functions that include assessment, planning, implementation, coordination, monitoring, evaluation, outcome measurement and general activities. Assesses previous home situation, mental and functional status, home care needs, and family support and agency involvement in patient's current care. Assist patient and family in deciding on discharge planning needs for post hospital care. Assesses currently availability of resources - community, family, financial, etc. - meet identified needs. Makes referrals and coordinates efforts of resources with patient and family. Follows up to ensure appropriate arrangements are made and needs met once patient is discharges. Reviews medical services for appropriateness, necessity, timeliness, and efficiency, as well as need for continued stay and benefit coverage.

JOB REQUIREMENTS

Minimum Education

Holds an active Registered Nurse license and is eligible to practice in the state of Kentucky. 

Current BLS certification

Associates degree in a health-related field required; Bachelor's degree preferred.

Minimum Work Experience

Minimum of 5 years health care experience. 3 years of this health-related experience must be in an acute care setting. Post-acute experience strongly preferred.

Prior experience with Medicare reimbursement, medical necessity guidelines preferred.

FUNCTIONAL DEMANDS

Physical Requirements

Sitting - 1-15%

Walking - 16-31%

Standing - 16-31%

Bending/Squatting - 1-15%

Climbing/Kneeling - 1-15%

Twisting - 1-15%

Visual and Hearing Requirements

Must be able to see with corrective eyewear.

Color vision ability required.

Must be able to hear clearly with assistance.

Frequent talking and hearing when communicating with patients, members of their families, physicians and other staff members.

Other Physical/Environmental Demands

Lifting - 0-50 lbs, 50 or more with assistance

Carrying - 0-50 lbs, 50 or more with assistance

Pulling - Up to 100 lbs

Pushing - Up to 100 lbs

OSHA Category

Possible exposure to communicable diseases

Possible exposure to violent, inappropriate and aggressive patient behavior

Possible exposure to verbal abuse from patients and/or family members

LEADERSHIP CAPABILITIES

Mission, Service and Values

Supports the hospital Mission, Service and Values.

ESSENTIAL FUNCTIONS

• Makes discharge planning decisions, LOC, and LOS based on clinical documentation form other care providers appropriately.
• Uses appropriate terminology and knowledge of diagnostic tools to obtain pre-certification or continued stay justification form insurers.
• Demonstrates appropriate awareness for suspected abuse/neglect to pediatric, adolescent, adult, and geriatric patients and takes measures to report them according to policy.
• Assess patient's chart for current home situation including but not limited to psycho-social function, home care needs, family support, functional ability and agency involvement in the patient's care.
• Reviews and evaluates medical services for necessity, appropriateness, timeliness, and efficiency of treatment and service.
• Coordinates discharge of patient to home, nursing facility, home health agency, home with family and DME, transportation provider and community resources.
• Assesses current availability of needed resources and makes appropriate referrals to those resources.
• Ensures communication with third party payors that require notification of admission and treatment to ensure payment.
• Conducts pre-admission review on elective admissions to determine lever of care required and or opportunity for improvement in documentation by care provider.
• communicates with insurers, medical treatment team, family and patient, and care providers assure coverage for treatment, available options for alternate care and follow up for patients making recommendations where appropriate.
• Monitor and evaluate all patients, OP/IN/OBS for appropriateness of admission and continued stay.
• Processes appeals of any hospitalization of portion of hospitalization that is denied in an attempt to obtain a reversal of decision.
• Acts as a liaison with clinical and non-clinical services such as registration, business office, data processing, physician offices to obtain information required for appropriate care, follow up, pre=certification, certification a