What are the responsibilities and job description for the Case Manager - Geri-Psych position at Nacogdoches Memorial Hospital?
Position Summary
The Geri-Psych Case Manager RN is responsible for coordinating medical necessity determinations for inpatient admissions and outpatient procedures. This role ensures efficient utilization of hospital resources, facilitates discharge planning, and supports compliance with regulatory requirements. The Case Manager RN works closely with physicians, nursing staff, patients, and external agencies to ensure high-quality, cost-effective patient care while optimizing reimbursement processes.
Essential Duties & Responsibilities Utilization Review & Case Management
The Geri-Psych Case Manager RN is responsible for coordinating medical necessity determinations for inpatient admissions and outpatient procedures. This role ensures efficient utilization of hospital resources, facilitates discharge planning, and supports compliance with regulatory requirements. The Case Manager RN works closely with physicians, nursing staff, patients, and external agencies to ensure high-quality, cost-effective patient care while optimizing reimbursement processes.
Essential Duties & Responsibilities Utilization Review & Case Management
- Conducts reviews of patient admissions and continued hospital stays to ensure medical necessity.
- Identifies patients needing case management through admissions screening, chart review, and discharge planning meetings.
- Performs case management assessments and collaborates with interdisciplinary teams for discharge planning.
- Provides guidance to hospital staff regarding regulatory requirements, reimbursement policies, and utilization guidelines.
- Reviews observation admissions twice daily to determine appropriate utilization of services.
- Coordinates with the physician advisor on cases that do not meet acute care criteria.
- Ensures timely documentation and submission of third-party payer reviews and medical necessity determinations.
- Educates patients, families, and healthcare providers on the medical necessity process and regulatory requirements.
- Assists physicians in ensuring complete documentation of patient severity and required services.
- Clarifies treatment plans and collaborates with attending physicians to support appropriate care decisions.
- Identifies potential delays in care and refers cases to the appropriate department or physician.
- Ensures referrals are completed for patient discharge needs, including home health, skilled nursing, DME, and social services.
- Coordinates incoming patient transfers and facilitates outgoing transfers when appropriate.
- Prepares cases for physician advisor review, ensuring proper documentation and clear presentation of concerns.
- Keeps current with regulatory requirements, including CMS, Medicare, Medicaid, TJC, and other compliance standards.
- Monitors and reports on hospital utilization data to improve efficiency and patient outcomes.
- Supports hospital and department mission and vision through best practices in case management.
- Attends department meetings and completes required education and competency training.
- Collaborates with nursing, medical staff, and ancillary departments to improve patient care processes.
- Serves as a resource for utilization and medical necessity issues across hospital departments.
- Required: Licensed Registered Nurse (RN) in the State of Texas or Nursing Compact Licensure.
- Preferred: LVN licensure may be considered with significant experience.
- Preferred: Experience in emergency or psychiatric nursing.
- Preferred: Knowledge of federal and state regulations related to admissions, utilization review, and case management.
- Strong communication and interpersonal skills for working with patients, families, and healthcare teams.
- Critical thinking and analytical skills for evaluating patient needs and making care recommendations.
- Proficiency in electronic medical records (EMR) and hospital case management systems.
- Ability to manage multiple cases efficiently while maintaining compliance with regulatory standards.
- Sitting for extended periods (61-100% of shift) with occasional standing/walking.
- Frequent bending, squatting, reaching, and lifting up to 50 lbs.
- Use of hands for fine motor skills and documentation tasks.
- Primarily works indoors in a hospital setting with exposure to infectious diseases.
- Potential exposure to bloodborne pathogens, hazardous chemicals, and patient bodily fluids.
- Adherence to PPE requirements and infection control protocols.
