Case Manager-ED

Kingman Healthcare•Kingman, AZ

22h•Onsite

About The Position

All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision to be among the kindest, highest quality health systems in the country. In collaboration with providers, screen patients to identify and support the delivery of the most appropriate level of care and service. The ED Case Manager screens patients to identify those that require admission with identification of appropriate level of status assignment, those that do not require admission, and those with multiple presentations to the ED who may require intervention to avoid future unnecessary ED visits. In addition, the ED Case Manager ensures the unit base Case Managers have the appropriate information when the patient is admitted. Completes initial UR review on 100% of patients admitted during scheduled shift and completes all data entry into required documentation tools prior to end of shift. Assists with appropriate compliance of regulatory requirements, both State and Federal, including delivery of Hospital Initiated Notices of Non-coverage (HINN). Reviews non-emergent transfers into the hospital for medical necessity of admission. Provides physicians with alternatives to admission when patients do not meet medical necessity guidelines for admission to the facility.

Requirements

Graduate from an accredited school of nursing or bachelor’s degree in related health/behavioral/social science field.
At least one (1) year acute care setting experience or three years sub-acute experience.
RN’s must be licensed and currently registered as an RN in the state of Arizona.
BLS through the American Heart Association or American Red Cross.
Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
Knowledge of community resources to meet post-discharge clinical and social needs.
Possesses excellent interpersonal communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues.
Strong analytical and PC skills.
Ability to work cooperatively and develop collaborative relationships with physicians, families, patients, interdisciplinary team, and other community agencies.
Ability to work with people of all social, economic, and cultural backgrounds; be flexible, open-minded, and adaptable to change.
Demonstrates the ability to connect patients and families with necessary services, both inside and outside of Kingman area.
Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited payment resources.
Minimum of three years varied acute care hospital experience.
Minimum of two years of clinical experience in medical surgical or critical care nursing.
Able to handle multiple priorities simultaneously.
Demonstrates strong oral and written communication skills.
Able to manage technical business equipment i.e., phone, fax, computer etc.
Ability to sit for 3-5 hours per day.
Ability to stand for 3-5 hours per day.
Ability to walk for 3-5 hours per day.
Availability to work some evenings and weekends.

Nice To Haves

Graduate from an accredited school of nursing.
MSN or Master’s in related health/behavioral/social field.
Experience in utilization management, case management, discharge planning, and/or quality improvement.
ACMA or CCM.
Knowledge of clinical, social, insurance/financial, and physical factors that must be considered when evaluating how a patient’s expected post discharge care needs can be met.
Knowledge of clinical and social factors that may affect the patient’s functional status at discharge.
Three to five (3-5) years of recent acute hospital care experience.
One to two (1-2) years of experience in Utilization Management or Case Management.
Certified care manager (CCM) or accredited care manager (ACM).
Three to five (3-5) years of clinical experience in medical surgical or critical care nursing.
Two (2) years of experience in Utilization Management or Case Management.

Responsibilities

Collaborates with Physicians, Nurses, Social Workers, and other hospital departments as necessary, to facilitate the improvement in the quality of care and/or the efficiency with which hospital services are utilized.
Ensures the active involvement of the patient and or family in the evaluation process and provides assistance with planning and arranging post hospital services.
Identifies appropriate community resources for each assigned patient and works collaboratively with patients, families, multidisciplinary team members and community agencies to achieve desired patient outcomes.
Ensures initial implementation of the discharge plan and appropriate education regarding discharge plan to patient and family to facilitate a safe transition of care from the hospital to home or another facility.
Performs Utilization Review (UR) to determine medical necessity for admission, continued stay, appropriate utilization of resources and level of care determination based upon MCG criteria.
Communicates medical necessity information with the requesting Payers, as per KHI policies and procedures.
In conjunction with the Discharge Care Coordinator, determines whether required post discharge services are covered by the patient’s payer and informs patient of coverage determinations.
Maintains accurate and timely documentation of patient assessments, continuing reassessments and discharge plans.
Participates in Multidisciplinary Rounds (MDR) to share information and facilitate the health care team in meeting the patient’s medical and psychosocial needs.
Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to the mission and vision of Kingman Regional Medical Center.
Conducts assessment and evaluation of admitted patients for medical, physical, and psychological factors that may contribute to their disease process and may require specific or complex continuing care and/or supportive services.
Reviews medical records concurrently and retrospectively as necessary to assess the management of cases by comparing progress to predetermined criteria.
Evaluates for medical necessity, level of care, coverage issues, appropriate utilization of resources, and planning by reviewing physician documentation to ensure that MCG criteria is met.
Collaborates with members of the healthcare team concerning patient’s assessment, goals, care plan and progress.
Performs ongoing assessments of patients for continuing care needs such as, Skilled Nursing Facilities (SNFs), acute Long Term Care Facilities, Durable Medical Equipment (DME), and Home Health.
Participates in Multidisciplinary Rounds (MDR) to assist with the development of care plans that will meet the patient’s current and continuing healthcare needs.
Serves as an advocate for the patient and protects patients’ rights as they pertain to the ethical and legal issues of confidentiality during the case management process.
Based on patient assessment, develops a discharge plan, per KHI’s Discharge Planning policy, to coordinate the provision of goods and services with referrals to specific providers, and ensures initial implementation of the discharge plan in collaboration with the Discharge Care Coordinator.
Based on patient’s assessment and collaboration with the healthcare team, and the patient/family, the Case Manager develops and documents the discharge plan by identifying the needs of the patient and the availability of resources to ensure a safe transition from the hospital.
The Case Manager assists patients and their families with needs, such as complex discharge planning needs, suspected emotional, cognitive, or mental problems, financial issues, and home/environmental issues.
When identified, refers all suspected child and elder abuse/neglect concern to the appropriate agency.
Participates in MDR to ensure effective communication and collaboration for patients identified as having complex needs.
When necessary, determines which cases will require medical staff review and/or UR management intervention based upon KHI’s Utilization Management Plan.
Communicates with the attending physician, expected length of stay, Medicare guidelines and individual variances.
Proficiently utilizes MCG and applies clinical guidelines and criteria appropriately to make utilization determinations.
Inputs data into MCG when needed.
Communicates frequently with the UR Nurse and provides requested data timely.
Participates in committees, performance improvement activities, mandatory in-services, and continuing education.
Maintains compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines.
Performs additional duties, as requested, such as focused studies, appeal letters, outlier reporting, etc.
Completes initial UR review on 100% of patients admitted during scheduled shift and completes all data entry into required documentation tools prior to end of shift.
Assists with appropriate compliance of regulatory requirements, both State and Federal, including delivery of Hospital Initiated Notices of Non-coverage (HINN).
Reviews non-emergent transfers into the hospital for medical necessity of admission.
Provides physicians with alternatives to admission when patients do not meet medical necessity guidelines for admission to the facility.