Case Manager - RN, Our Lady of the Lake Health

FMOLHS•Baton Rouge, LA

About The Position

The Case Manager 1 directs utilization review of patient charts and treatment plans, discharge planning, and assessment of care and treatment criteria for patients in an assigned department. The role specializes in reviewing information related to its assigned area and relies on education, experience, professional training, and judgment. It works under minimal supervision and calls for a wide degree of creativity and latitude. The Case Manager contributes to cost-effective care and financial outcomes by applying a continuum-of-care philosophy, understanding benefit systems and healthcare delivery requirements, and coordinating with treatment teams, physicians, payors, agencies, and community resources. The role assesses patient needs, supports appropriate treatment and discharge planning, and helps ensure patients receive the appropriate level of care.

Requirements

Three years of experience in general or specialty nursing practice.
Associate's degree.
Current and unrestricted Louisiana State License as an RN.

Responsibilities

Contribute to cost effectiveness and efficiency, and demonstrate awareness of benefit systems and cost-benefit analysis.
Maximize financial outcomes for assigned patients using the continuum-of-care philosophy.
Assist in developing, monitoring, and analyzing annual financial goals for the targeted population.
Understand the capabilities of outside referral sources, including home health, sub-acute care, and skilled nursing facilities.
Understand healthcare delivery systems and payor prior-approval requirements for admissions, procedures, and continued stays.
Meet with the treatment team to provide utilization review information and discuss continued stay, discharge, and aftercare plans; evaluate financial resources and documentation supporting continued stay and level of care.
Use utilization review techniques to work with physicians, third-party payors, and federal and local agencies to help prevent payment or day denials.
Serve as a resource for unit personnel resolving utilization and case-management problems, and communicate identified problems to appropriate personnel.
Collaborate with the healthcare team to support reimbursement optimization, appropriate discharge planning, and cost-effective quality care.
Assess patients' referral and alternate-level-of-care needs as part of discharge planning.
Track and report avoidable days.
Coordinate and deliver services competently, including assessing physical or mental impairment, reviewing clinical information, and developing treatment and discharge plans with the healthcare team.
Evaluate the quality of necessary medical services, apply criteria to determine medical necessity, and work with physicians on appropriate alternative levels of care.
Provide timely information to third-party payors, coordinate denials and appeals, and help ensure patients receive the appropriate level of care.
Access and use community resources; understand the ADA and other federal legislation affecting individuals with disabilities; and establish client support systems.
Follow departmental and hospital policies and procedures, as well as safety, quality assurance, and infection-control standards.
Maintain current knowledge through relevant seminars, workshops, professional conferences, and affiliations with national and state professional organizations.
Perform other duties as assigned or requested.