Case Manager (RN) - Case Management * Evenings - 36hrs/wk.
Requisition #: req11831
Shift: Evenings
FTE status: 0.9
On-call: No
Weekends: Yes
General Purpose of Job:
The Case Manager works in partnership and in a leadership role with physicians and the interdisciplinary team to coordinate the care and service of selected patients across the continuum. This role’s underlying objective is to enhance the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates, coordinates and promotes efficient and effective utilization management, care facilitation and discharge planning functions.
Knowledge, Skills and Experience:
Education:
- High school diploma/GED
- Bachelor of Science in Nursing preferred
License / Certification / Registration:
- Current and valid Michigan R.N. license
Experience:
- Minimum of three years clinical nursing experience (acute care preferred)
Skills & Abilities:
- Skill and proficiency in applying managed care principles and concepts to the case management process.
- Knowledge of and skill in the use of computers and related systems and software preferred.
- Skill in observation and critical thinking, demonstrated by effective decision making, and use of appropriate problem-solving methods.
- Skill in excellent interpersonal, oral, and written communications required. A high degree of professionalism is essential for all contact with patients, family members, clinical personnel, physicians, outside referral sources, and members of the community.
- Ability to make effective decisions, judgments and incorporate problem-solving methods.
- Ability to be persistent in working through and/or resolving issues and problems required.
- Ability to work independently and professionally, set priorities and take initiative while working efficiently and using good judgment required.
Essential Duties:
This job description is intended to cover the minimum essential duties assigned on a regular basis. Team members may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.
Utilization Management:
- Applies approved clinical appropriateness criteria for assigned patients to monitor appropriateness of admissions and continued stays, and documents findings accordingly based on policy. Evaluates for appropriate setting and level of care.
- Refers inappropriate observation or anticipated admission cases to the Physician Advisor.
- Explores strategies to reduce length of stay and resource consumption while maintaining optimal patient outcomes. Takes action to achieve continuous improvement in both areas.
- Obtains certification for unscheduled/emergency admissions, as directed by health plan. Negotiates with payors to get coverage for out-of-plan services.
- Collaborates with providers and ancillary departments to arrange the most cost-effective treatment plan.
- Reviews medical record for issues related to quality, risk management and appropriate utilization of services.
- Identifies potential denials or “No Bills” and develops a plan of action to address the issue with the Supervisor of Case Management.
- Functions as a resource for the principles of the managed care process for physicians and other disciplines and promotes case management through role modeling and education of the healthcare delivery team as related to the appropriate disposition for the patient.
Discharge Planning:
- Assists with social work to coordinate/facilitate patient care progression throughout the continuum.
- Coordinates discharge plan with patient, family, physicians and inpatient/outpatient staff to assure an individualized, timely and effective transition to the next level of care. Continues to monitor and assess for discharge planning needs as appropriate.
- Collaborates and communicates with all members of the multidisciplinary team in all phases of discharge planning process; including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching and ongoing evaluation.
- Monitors and evaluates effectiveness of the discharge planning process through outcome analysis across the continuum as appropriate.
- Seeks consultation from appropriate disciplines/departments as r