RN Case Manager

Job Description

Job Description

Summary : Role has multiple components : clinical, leadership, and educational. Major areas of accountability include utilization management, care co-ordination, discharge planning, and quality management.

Goal is optimal patient care at appropriate level, in financially expedient and efficient manner. Inherent in this process is monitoring and tracking / trending of data.

The Case Manager is responsible for monitoring of clinical documentation with guidance to physicians and extenders as needed.

Compliance with all hospital COPs

Utilization Management

• Insures care delivered in fiscally responsible manner
• Reviews inpatient, observation cases using nationally accepted criteria for appropriate level of care, discharge and continued stay
• Reports exceptions, variances to Utilization Review Committee and / or responsible staff
• Makes informed recommendations as to Level of Care, Length of Stay,

Documentation for medical necessity

• Insures payer requirements met to insure payment for services rendered. Appeals as needed. Monitor for trends, patterns and refers to Utilization Review Committee or appropriate staff
• Compiles, integrates information as needed
• Participates in Utilization Review Committee as member
• Acts as liaison with payers, CMS, QIO as needed
• Co-ordinates and educates hospital staff as needed
• Maintains current and up to date knowledge of current Utilization strategies

Case Management / Care Co-Ordination

• Strives for efficient care across the continuum
• Reviews continued stays using nationally approved criteria
• Tracks / trends information and reports to Utilization Review Committee and appropriate staff
• Assess patient for discharge needs
• Coordination of discharge needs with personnel for DME, HH, and follow up
• Insures payer requirements met for reimbursement
• Participates in educational programs such as Joint Camp as needed
• Is available for physician education / interaction

Discharge Planning

• Considers, addresses and coordinates needs outside of facility
• Assesses patient on admission or within one business day for discharge needs
• Coordinates, arranges services as needed
• Complies with payer requirements to maximize reimbursement for post discharge services and minimize cost to patient
• Complies with federal and state regulations concerning financial interest disclosure and choice of provider
• Compiles statistics and monitor for trends. Report as required to Utilization Review Committee and or responsible party.

Quality

• Continues to promote quality healthcare as a means to the goal of patient satisfaction
• Practices continuous vigilance for potential quality issues in all areas of expertise and all assigned areas
• Addresses concerns in a timely manner and appropriate fashion. Compiles information and statistics.
• Reports tracking and trending results to appropriate committee and department heads
• Continues to maintain current information to facilitate recognition of quality issue
• Maintains up to date information bank

Education and Experience

Degree or Formal Training : Associate or Bachelor's Degree in Nursing

License, Certificate or Registration : Current LA State Licensure

Additional Information :

BLS Required

Benefits are offered with this position after a waiting period.