What are the responsibilities and job description for the Manager of Case Management position at Rivers Health?
Provides management oversight of the Care management services at Rivers Health including Case Management, Utilization Management and Social Services. Contributes to the mission and goals of the hospital by ensuring the effectiveness of the department and compliance with accreditation and payer standards
- Communicates with Physicians to assure patient meets admission
criteria and level of care determination is correct.
- 2. Assesses patient needs for case management intervention through data
gathering, treatment plans, resource utilization, and cost
management; coordinates patients' process of care throughout the
continuum of care.
- 3. Determines the anticipated DRG, length of stay, and transfer
or discharge date. Communicates and collaborates to manage LOS
outliners and observation stay greater than 48 hours.
- 4. Collaborates with the physician to share assessments, goals and
plans for patients' episode of illness; consults with them on
patients progress toward expected outcomes.
- 5. Provides ongoing assessment of patient care needs through frequent
visits and communication with other members of the health care team.
- 6. Tracks major events in the hospitalization process and discusses
with the patient, family or significant others patient progress and
outcomes they can reasonably expect.
- 7. Manages referrals to external physician advisor for level of care
consultation and physician peer to peer review.
- 8. Identifies patients' individual needs in such areas as social and
economic influences, family resources, functional abilities,
knowledge needs, potential risk factors, complications and special
issues, determine strategies to facilitate appropriate resolution
and cost-effective outcomes.
- 9. Serves as hospital liaison to insurance companies. Ensures clinical data is provided to support admission to insurance companies timely. Sends updates as required.
- 10. Identifies and/or coordinates resources patients may need upon
discharge, ensures discharge teaching is completed and documented.
- 11. Assumes advocacy role for patients during hospitalization; makes
appropriate referrals to community agencies/resources.
- 12. Completes financial clearance including benefits, authorization,
clinical submission, etc., on all swing bed and inpatient rehab.
admissions.
- 13. Ensures completion of PASSR as required for swing bed admissions.
- 14. Serves on patient teams and committees as assigned both internal and external to the hospital organization.
- 15. Participates in quality improvement and evaluation processes related to the case management practice.
- 16. Investigates inpatient denials. Takes appropriate action for appeal and maintains required denial statistical data.
- 17. Performs other job-related duties as assigned.
- 18. Complies with Corporate Policies, Departmental Policies and
Procedures and Personnel Employee Handbook.
- 19. Demonstrates excellence in customer service skills.
- 20. Fosters an atmosphere of teamwork and collaboration.
- 21. Attends mandatory in-services.
- 22. Management oversight of all team members to produce length of stay appropriate to the diagnosis of the patient.
- 23. Ensures all discharge needs are addressed for patients prior to
QUALIFICATIONS:
The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this position.
EDUCATION AND FORMAL TRAINING:
Bachelor's degree in nursing preferred. Graduate of an accredited school
of nursing required. West Virginia nursing license is required.
WORK EXPERIENCE:
A minimum of five years' experience in an acute care setting required.
Experience in Utilization Review, Discharge Planning or Case Management
required.
