RN Case Manager

DIRECT SUPERVISION BY:

Chief Nursing Officer

DIRECT SUPERVISION TO:

None

JOB SUMMARY

• The Case Manager is responsible for a broad range of functions within the hospital including the Swing Bed program. They will be required to work closely with other departments, patients, family members, employees and outside agencies. They are responsible with assisting administrative staff to promote hospital’s compliance with local, state and federal agencies.
• Collects, analyzes and reports a variety of data to assess the quality and appropriateness of care and treatment of patients.
• Works with Hospitalist, nursing staff and ancillary departments to verify insurance coverage, obtain precertification and recertification of hospitalization for sing bed patients.
• Coordinated follow up care and services for discharged patients.

JOB FUNCTIONS:

• Performs case management in accordance with all state mandated regulations. Maintains compliancy with regulation changes affecting case management. Reviews patient records and hospitalization. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct reviews. Reviews and validates physician’s orders, reports progress and unusual occurrences on patients.
• Prepares information for notification letters for providers and employees. Receives and processes requests for appeal of denials. Responds to complaints per Case Management guidelines. Maintains utility review and appeal logs, as needed, by state.
• Analyzes patient records, and participates in interdisciplinary collaboration with professional staff.
• Conducts admission and continued stay reviews utilizing the appropriate severity illness/intensity of service criteria and pertinent nursing knowledge.
• Reviews, documents, and communicates all UR activities and outcomes, to other departments, physicians, and employees to obtain information necessary to make determinations.
• Refers cases that failed to meet established criteria to UR physician in a timely manner.
• Provides denial of benefit letters to patients/responsible financial parties giving a reason for denial.
• When appropriate, make available alternatives to the acute care setting and hospital services in an effort to maximize resource utilization.
• Develops plan of care which identifies and facilitates goals as determined by the patient, family, primary care giver, physician and the interdisciplinary team.
• Works in conjunction with business office staff to receive pre-authorization numbers on patients in the inpatient area.
• Checks all admissions records for post discharge needs.
• Conducts interviews with the patient and their family regarding the patient’s needs prior to being discharged. Initiates home health referrals on the patient’s requirement these services after discharge.
• Assist the family in getting needed equipment set-up.
• Initiates the proper paperwork for patient’s needs after their discharge, i.e., nursing home placement, home health, hospice care, home equipment set up.
• Initiates level 1 screening on the day of admission for potential nursing home patients as ordered by physician.
• Discusses the patient’s conditions with their attending physician, as it is related to their needs after discharge, i.e., nursing home placement, home health, hospice care, home equipment set up.
• Identifies alternative solutions with the physicians to get patient out of the hospital and into an alternative situation as quickly as possible.
• Monitors patients daily that have reached their maximum hospital benefits.
• Evaluates all self pays status and make recommendations to additional resources.
• Informs physician of the self-pay status.

ADDITIONAL REQUIREMENTS

• Completes projects and task in a timely manner.
• Demonstrates a positive interpersonal relationship when dealing with other departments, patients, family members, employees and outside agencies.
• Adheres to all departmental and hospital polices especially those dealing with HIPAA.
• Maintains current knowledge of various regulatory agencies and communicates them to other departments.
• Participates in external and internal meetings and committees as requested
• Demonstrates accuracy, completeness, thoroughness and neatness in work submitted.
• Creates and maintains by example, an open positive work environment by utilizing effective human relations and communication.

· Participates in Weekend Case Management call rotation.

QUALIFICATIONS:

EDUCATION AND TRAINING

• Licensed as an Licensed Practical Nurse and/or Registered Nurse in the State of Georgia
• Knowledge of, case management, utilization review and outside regulatory agencies
• Knowledge of state hospital law and regulations.

.

MINIMUM WORK EXPERIENCE

• Minimum of two year’s current experience in a hospital setting.

SKILLS AND ABILITIES

• Must be able to communicate effectively in writing or verbally to patients, physicians, staff, visitors, employees, and regulatory agencies.
• Must be able to follow verbal and/or written instructions.

PHYSICAL DEMANDS

Ability to walk or stand for long periods.

Ability to move heavy patients and equipment.

Repeated bending, squatting, and stooping.

Normal or corrected vision and hearing.

Reaching and bending, including reaching above shoulder height.

Ability to lift, carry, push, pull a minimum of 50 pounds.

Ability to perform shift work including working 12 hour shifts

On call

Ability to communicate with employees, patients and visitors.

Ability to remain calm under stress.

ANALYTICAL SKILLS

Ability to evaluate a situation and provide the necessary duties and expertise.

Ability to delegate duties and responsibilities in order to provide quality care for the patient, while managing assigned personnel as efficiently as possible.

Ability to communicate well within the department and with the other departments.

Ability to assume function in a charge position after appropriate orientation.

HAZARDS

Exposures to toxic/caustic/chemicals/detergents

Exposure to extreme conditions, hot/cold

Exposure to dust/fumes

Exposure to moving mechanical parts

Exposure to potential electrical shock

Exposure to x-ray/electromagnetic energy

Exposure to high pitched noises

Exposure to communicable diseases

Exposure to Blood Borne pathogens, and body fluids

Gaseous Risk Exposure

Use of a fitted respirator

PHYSICAL WORKING ENVIRONMENT

Well-lighted, well-ventilated work areas.

Work under stress and under the conditions that normally exist in a hospital.

SPECIAL DEMANDS:

Ability to work both cooperatively and independently, to work efficiently under stress, to utilize sound professional judgement in establishing priorities and intervening in urgent and emergent patient care situations.

Ability to promote a positive public image of the nursing unit and facility by communicating in a polite, tactful, and professional manner with patients, families, visitors, and co-workers.

Required to work in areas other than those assigned.

Job Type: Full-time

Benefits:

• Dental insurance
• Employee discount
• Health insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• On call

Work Location: In person