Case Manager - RN

FMOLHS•Monroe, LA

About The Position

The Case Manager 1 directs utilization review of patient charts, treatment plans, and discharge planning related to quality of care and treatment criteria for patients in a specific department. The role specializes in reviewing information for assigned areas and relies on education, experience, professional training, and judgment to fulfill responsibilities. A wide degree of creativity and latitude is expected, and the Case Manager works under minimal supervision. Responsibilities include reviewing admissions and ongoing treatment for appropriateness, coordinating discharge planning and referrals, collaborating with interdisciplinary teams and payors, monitoring care for quality and compliance, and tracking avoidable days and denials. The Case Manager also supports continuity of care through communication with physicians, patients, families, staff, and community agencies, and serves on committees as requested.

Requirements

Three years of clinical experience.
Graduate of an accredited RN program.
Current Louisiana State license as an RN.
Good computer skills.
Interpersonal and human relations skills.
Oral and written communication skills.
Problem-solving and critical-thinking skills.
Time-management and prioritization skills.
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 for assistance and consult Social Services for patients with complex or high-risk discharge needs.
Monitor care and services for opportunities for improvement or deviations from standards of care, protocols, and core measure pathways.
Notify staff, physicians, payors, and patients of discharge plans and the actions needed to implement them.
Initiate and complete activities required to facilitate a smooth and timely discharge from the acute care setting, identifying patient needs and using available resources.
Determine and implement appropriate intervention strategies and solutions using clinical judgment, knowledge, and critical thinking.
Notify involved entities, including the EHR, when an admission fails to meet criteria, and document the information promptly.
Immediately notify the Business Office when category changes occur.
Notify payors of admissions and discharges according to protocol, communicate accurate coverage information, and 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 such as length of stay and core measures.
Notify physicians when additional documentation or treatment-plan adjustments are needed to promote continuity of care, and suggest ways to improve service efficiency and resource use.
Interact positively, competently, and respectfully with patients, families, caregivers, staff, coworkers, physicians, and community agencies.
Track avoidable days and denials, submit information to the Director and/or Manager, and complete avoidable-day documentation promptly 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.
Promote high-quality care by ensuring core-measure guidelines are followed through concurrent chart review and follow-up with healthcare providers.
Conduct concurrent appeals and notify the Director of Case Management of all denials for prompt tracking.
Prepare avoidable-day sheets, notify appropriate personnel, and communicate with physicians about needed documentation or treatment-plan adjustments.
Complete other duties as assigned and actively serve on committees as requested.