Overview

The case manager coordinates with physicians, nurses, social workers and other health team members to expedite medically appropriate, cost-effective care (Care Coordination). The case manager applies clinical expertise and medical appropriateness criteria and works with physicians to determine appropriateness of hospital stay and appropriate level of care determination (Utilization Review) The case manager assesses patients at admission to begin discharge planning and works with a multidisciplinary team to facilitate appropriate and timely discharge (Discharge Planning).

Responsibilities

Key Responsibilities / Essential Functions

1. On admission, initiates discharge planning by assessing patients needs and documenting the assessment on the IPOC notes.

2. Contributes to the interdisciplinary plan of care and ensures that the plan is consistent with the discharge plan and patient’s continuing care needs.

3. Assist with discharge screening on all patients admitted and identifies patients who have complex physical, psychosocial, financial, or other discharge planning needs and refers those patients to the social worker.

4. Using established criteria, assesses assigned patients for appropriateness of admission, need for continued stay, and takes appropriate action to ensure correct patient status.

5. Communicates with external review agencies in a timely manner regarding concurrent patient review.

6. Communicates with business office regarding insurance contracts and status of observation patients.

7. Discusses with attending physicians appropriateness of admission, continued stay, resource utilization, consultations, estimated length of stay and discharge plan.

8. Refers appropriate cases to the Physician Advisor.

9. Participates in interdisciplinary patient meetings on assigned units to coordinate the elimination of barriers to efficient delivery of care in the appropriate setting.

10. Coordinates activities to ensure patient’s appeal rights under the discharge appeal program.

11. Ensures that patient receives Important Message from Medicare as required upon admission and discharge.

12. Assures that chart documentation consistently meets department and organizational standards.

13. Documents reviews and findings on appropriate paperwork and/or software.

14. Demonstrates knowledge of federal and state regulations in regard to Medicare, Medicaid, Champus and other government agencies in healthcare.

15. Maintains clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.

16. Participates in the quality improvement process for Case Management Department.

17. Attends Department and Team staff meetings. Must attend at least ¾ of scheduled meetings.

18. Performs additional duties as assigned.

Qualifications

Minimum Knowledge, Skills, Experience RequiredEducation: Graduate of accredited School of Nursing with current Alabama licensure.EXPERIENCE: Three years clinical experience preferred. Comparable combination of education and experience will be considered. Previous utilization management, discharge planning or hospital based social service experience is preferred. Additional Skill/Abilities: Must have excellent communication skills with the ability to work in a fast paced environment, requiring prioritizing and changing tasks frequently and quickly.