RN Care Manager - Care Management

Minimum Qualifications:

RN with Bachelor's degree in Nursing and two years of inpatient experience in a hospital environment.  Current license or valid permit to practice professional nursing in Texas.

Job Description:

To support the physician and interdisciplinary team in the provision of patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. The role integrates and coordinates utilization management, care coordination and discharge planning functions.

Essential Job Functions:

• Utilization Management
• Ensure clear admit status and  timely management of observation patients
• Demonstrates knowledge of CMS guidelines and use of Local Coverage Determination (LCD) or inpatient and observation,  CMS inpatient only list, and other payor guidelines as required
• Demonstrates thorough knowledge in the application of InterQual criteria; Severity of illness (SI), Intensity of service (IS), Discharge screens (DS) SI, IS, and performs continued stay reviews for Medicare, Medicaid and self pay patients
• Demonstrates skill in accurately entering required UM data. Works closely with denials/appeals coordinator
• Elevate to department leadership all patients not meeting medical necessity criteria after impasse with attending physician
• Creates final patient discharge disposition (closing of cases)

 Level of Care:

• Ensure appropriate level of care/patient status
• Facilitate clinical care progression of patient by multidisciplinary team throughout stay
• Demonstrates knowledge of CMS guidelines and use of LCD for inpatient and observation,  CMS inpatient only list, and other payor guidelines as required
• Demonstrates appropriate application of InterQual LOC criteria to evaluate current patient care needs.
• Elevate to department leadership all patients in an inappropriate level of care after impasse with attending physician
• Documents avoidable days
• Assessment of patients’  financial, emotional, physical, social, functional and health care needs
• Demonstrates ability to assess discharge needs of all patients, and ability to prioritize patients by need, e.g. Medicare, high risk diagnoses, high risk for readmission, identified vulnerable patients
• Identify readmission risk and target interventions to reduce risk for readmission
• Define and recommend potential discharge plan
• Utilize assessment to begin management of patient and family expectations regarding the plan of care
• Care Coordination of Treatment Plan: Medical and Multidisciplinary
• Participate in multidisciplinary rounds. Facilitates clinical care progression of multidisciplinary team in a timely and efficient manner
• Facilitate Patient Care conferences based on patient/family needs
• Manage patient and family expectations the plan of care
• Contact appropriate ancillary department with any delays impacting care progression
• Address incomplete, unclear medical plan of care with attending physician. If unsuccessful, elevate to department leadership, director or physician advisor as appropriate.

Salary: 

Salary commensurate with experience