Case Manager - RN

FMOLHS•Monroe, LA

About The Position

The Case Manager 1 directs utilization review of patient charts, treatment plans, and discharge planning in a specific department, focusing on quality of care and treatment criteria. The role specializes in reviewing information related to assigned areas and relies on education, experience, professional training, and judgment. A wide degree of creativity and latitude is expected, and the position works under minimal supervision. The Case Manager evaluates admissions and ongoing treatment for appropriateness, coordinates patient needs and discharge planning, and collaborates with physicians, payors, staff, patients, families, and other involved parties. The role also monitors quality and care standards, tracks avoidable days and denials, supports core measure compliance, and performs other duties as assigned.

Requirements

Three years of clinical experience.
Graduate of an accredited RN program.
Current Louisiana State license as an RN.
Good computer skills.
Good interpersonal and human relations skills.
Good oral and written communication skills.
Good problem-solving and critical-thinking skills.
Good time-management and prioritization skills.
Good organizational skills.

Responsibilities

Review admissions for appropriateness using established InterQual criteria within 24 hours of admission or the next working day.
Review current treatment plans daily to evaluate the appropriateness of services and progress toward treatment goals.
Identify appropriate referrals and consult Social Services for patients with complex or high-risk discharge needs.
Monitor care and services for opportunities for improvement and possible deviations from standards of care, protocols, or core measure pathways.
Notify staff, physicians, payors, and patients of discharge plans and actions needed to implement them.
Initiate and complete activities needed to facilitate smooth and timely discharge from the acute care setting within specified guidelines and timeframes.
Identify patient needs and use available resources to meet them; determine and apply appropriate intervention strategies and solutions using clinical judgment and critical thinking.
Notify involved entities, including the EHR, when an admission fails to meet criteria and document the notification promptly.
Immediately notify the Business Office when category changes occur and notify payors of admissions and discharges per protocol.
Communicate accurate information with payors and physicians to ensure coverage for services and care; promptly notify physicians and the Business Office of potential non-coverage issues.
Facilitate unit-based interdisciplinary team meetings and collaborate on discharge plans and unit- or disease-specific metrics, including length of stay and core measures.
Notify physicians when additional documentation or treatment-plan adjustments are needed to promote continuity of care.
Suggest ways for staff and physicians to improve service efficiency and minimize resource use.
Interact positively, competently, and respectfully with patients, families, caregivers, staff, coworkers, physicians, and community agencies.
Track avoidable days and denials; submit tracking information to the Director and/or Manager and complete avoidable-day documentation timely for peer review.
Promptly notify the Case Management Manager or Director of possible quality issues.
Maintain confidentiality when dealing with patient, staff, or physician issues.
Support high-quality care by ensuring core measure guidelines are followed through concurrent chart review and follow-up with appropriate healthcare providers.
Conduct concurrent appeals and notify the Director of Case Management of all denials for prompt tracking.
Prepare Avoidable Day sheets and notify appropriate personnel of review results.
Complete other duties as assigned and actively serve on committees as requested.