CARE MANAGER - RN - CASE MANAGEMENT

North Oaks Health System-posted 2 months ago
Hammond, LA
501-1,000 employees
Religious, Grantmaking, Civic, Professional, and Similar Organizations
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The RN Case Manager works collaboratively with patients, nurses, social workers, physicians, other practitioners, caregivers, and the community to facilitate care along a continuum with the goal to achieve optimal health, access to care, and appropriate utilization of resources, balanced with the patient's right to self-determination. This is done within the Standards of Practice and Scope of Services as defined by the American Case Management Association.

  • Contributes to the development of a goal-directed, age-appropriate plan of care through an interdisciplinary team process.
  • Assesses patients' biophysical, psychosocial, environmental, economic/financial, and discharge planning needs to assist in the development of patient-centered goals of care.
  • If needed, procures services and resources, serving as an advocate for patients and families.
  • Communicates patient needs and follows up with appropriate professionals (i.e., Social Worker, clinical pharmacist, diabetes educator, and dietician).
  • Assesses the appropriateness and timeliness of the level of care, diagnostic testing, clinical procedures, quality and clinical risk issues, and documentation completeness.
  • Communicates continually with physicians, patients, caregivers, and care team members to facilitate coordination of clinical activities to enhance a seamless transition from one level of care to another.
  • Seeks information and resources for use in creative problem solving for complex discharge planning, quality of care, and utilization issues.
  • Works collaboratively with other departments and services to define and study areas of inefficiency to participate in process improvement projects.
  • Studies available information to remain abreast of reimbursement modalities, community resources, review systems, and clinical and legal issues that affect patients and providers of care.
  • Serves as a resource and provides education to physicians, patients, caregivers, and professional staff on levels of care, quality of care issues, and regulatory concerns.
  • Provides orientation and mentoring to new staff members.
  • Fosters positive internal and external customer relations.
  • Works in accordance with applicable state and federal guidelines and with the unique requirements of reimbursement systems.
  • Knowledgeable about and acts in accordance with laws and procedures regarding patient confidentiality and release of information.
  • Performs other duties, projects, or subjects as assigned by departmental leadership.
  • Follows Infection Control policies and procedures at all times per system guidelines.
  • Coordinates transitions in care with payer source to minimize financial impact to patient/family and organization.
  • Reviews physician orders to ensure appropriate level of care orders are in the medical record.
  • Makes daily rounds to assess hospital inpatients.
  • Participates in interdisciplinary staffing meetings on behalf of the patient and physician.
  • Collaborates daily with physicians and care team members to support the assessment of continued need for acute care hospitalization services.
  • Communicates weekly to the department Manager/Director the discharge plan of any patient with a length of stay greater than five days.
  • Advocates for the patient, family, physician, and facility to obtain benefits from insurance carriers and others with the Utilization Review personnel.
  • Monitors and assists physicians with documentation compliance of core/quality measures.
  • Immediately reports to the Manager, Director, Physician Advisor and/or CMO any case not meeting continued stay criteria.
  • Provides Manager/Director with updates on any situation where the patient transition from one level of care to another is not proceeding as expected.
  • Reviews record of all patients in observation status on assigned area daily to establish proper start time and end time for observation services.
  • Communicates with the attending physician regarding the appropriate level of care placement based on the physician's determination and documentation.
  • Completes criteria reviews on all observation patients daily and new inpatient admissions to determine medical necessity.
  • Communicates patient needs, physician orders, and other pertinent information to any continuing care providers to facilitate a safe transition to another level of care.
  • Graduate of a RN program.
  • Registered Nurse licensed to practice in the State of Louisiana.
  • A minimum of three years of clinical nursing, case management and/or utilization review experience.
  • Emergency services and/or utilization review/case management experience preferred.
  • Knowledge of established medical necessity criteria and their application preferred.
  • Knowledge of Medicare, Medicaid, Managed Care Organizations, Social Services, discharge planning, community resources, and referral agencies strongly preferred.
  • Knowledge of ICD-10 coding, Case Mix Index monitoring, and legal compliance, and clinical documentation preferred.
  • Knowledge of Peer Review and payer functions preferred.
  • Knowledge of third party payor appeal process preferred.
  • Knowledge of Quality Improvement activities/Team Leader/Facilitator training preferred.
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