RN Care Manager

Under general supervision, manages and coordinates process of care for inpatients to facilitate quality cost-effective patient outcomes. Works collaboratively with interdisciplinary staff internal and external to the organization. Coordinates with payer and physicians to ensure the maximum reimbursement for the hospital through the utilization review process. Responsible for discharge planning and coordination of care with interdisciplinary team. Collaborates with service line team members to distribute patient case load.

Education

Bachelor of Science in Nursing (BSN) OR Associate of Science in Nursing and currently enrolled in a BSN program with an expected graduation date within three (3) years

Experience

Two (2) years of Case Management which includes, Discharge Planning and working with Re-Admission Initiatives.

Diversified, progressive experience in acute care and/or other settings within the continuum preferred

Skills

• Knowledge of care management theories, principles, and standards
• Skill in using computer software programs
• Advanced skill in oral and written communication
• Advanced skill in critical thinking
• Ability to resolve complex problems
• Ability to remain calm under pressure and intense time constraints
• Ability to assess discharge needs for patients

Licensures, Certifications

• Current state of Maryland Registered Nurse license
• Bachelor of Science in Nursing (BSN) OR documentation of current enrollment in BSN program with expected graduation within three years of hire

• Care Management highly desired.

Physical Requirements

• Ability to sit, stand, stoop, and bend.

Working Conditions

• Primarily on clinical units, evaluating patient records and interviewing patients and families, working with interdisciplinary staff up to 70% of time.  Remainder of time in office environment on the phone or performing electronic documentation.

Conditions of Employment

Maryland RN licensure – current and ongoing

Reports to

 DIRECTOR of Care Management

Patient & Workplace Safety

• Employee has knowledge and understanding of patient and workforce safety as it relates to job duties.

Patient Population

• Demonstrates competency in the delivery of care and applies the knowledge to meet age-specific needs if applicable.

Principal Duties and Responsibilities:

• Assesses patients within a defined caseload to identify clinical status, needs, issues, financial resources, and care goals; demonstrates knowledge of reimbursement mechanisms. Considers patient’s financial resources for meeting healthcare needs (insurance reimbursement, managed care plans, entitlement programs, and personal resources).
• Continually assesses patient care management needs through frequent rounds and communication with physicians and other appropriate members of the health care team. Serves as liaison for the patient, physician, and health care team to implement the processing of the patient centered plan throughout the continuum.
• Reviews the appropriateness of admission and continued stay criteria for a defined group of patients and either develops a concurrent stay and/or discharge plan of care in accordance with payer and clinical guidelines. 
• Identifies, plans, modifies, and coordinates patient discharge needs, making appropriate referrals, and utilizing available community resources as needed for implementation. Formulates a plan that addresses the continuing needs of the patient following discharge from the acute care setting.
• Maintains a working knowledge of the requirements and clinical criteria guidelines of payers. Coordinates services with managed care companies and other third party payers. Discusses on-site reviewer issues with payer, either via the telephone or in person.  Assures timely utilization compliance with all payers who require authorizations.
• Provides necessary services for effective post discharge placement in another facility, by obtaining necessary pre-authorization, transportation, and contacting (if necessary) the proposed facility regarding clinical information and services required.
• Identifies the need for, arranges, and conducts health care team meetings when necessary to facilitate the coordination of care and discharge planning for complex patients and high utilization of resources.
• Participates in education of physician, ancillary, and nursing staff regarding care management, financial and clinical outcomes, as well as documentation requirements/stan