Case Manager

CALDWELL COUNTY HOSPITAL INC•Princeton, KY

30d•Onsite

About The Position

The Case Manager role at Caldwell Medical Center encompasses several key functions: Transitional Care, Utilization Review, Discharge Planning, and Social Services. The Transitional Care component focuses on evaluating patients for the Swing Bed Program and managing ongoing utilization reviews for these patients. The Utilization Review component involves performing admission and continued stay reviews using approved criteria to ensure appropriate hospital-level care and resource utilization. The Discharge Planner component works with patients, families, providers, and agencies to ensure a safe and smooth transition from hospital or transitional care to home, including facilitating follow-up appointments and coordinating home care needs. The Social Services component provides support during crises and acts as a liaison between healthcare disciplines and patients/families, addressing complaints and concerns. This position requires active patient advocacy, collaboration with medical staff and other departments, and participation in multidisciplinary planning, including the discharge process. The role also involves assessing patient and family needs, intervening in crisis situations, and maintaining accurate documentation. The Case Manager is expected to promote professional development, maintain departmental policies and procedures, and support quality improvement initiatives. They will also work with the Business Office on payment issues and authorizations, and review Medicare, Medicaid, and private insurance requirements. The role requires a self-disciplined individual with strong interpersonal skills and professionalism, capable of functioning independently and managing various aspects of patient care and resource utilization.

Requirements

Associate Degree in Nursing with a license to practice in the state of Kentucky.
1-2 years experience in nursing.
Proficiency in this position should be reached in 2-4 months.
Must maintain CEUS as established by the KBN.
Must be willing to take specialty classes and other educational offerings as indicated.
Must be skillful in written and oral communication.
Demonstrates basic problem solving and time management skills.
Must have knowledge and skills required to deliver high quality nursing care utilizing sound nursing judgment.
Must demonstrate the ability to interact with other personnel in a positive fashion.
Must demonstrate the ability to work independently and to delegate appropriate tasks to others.
Must maintain certification in BLS.
Prolonged, extensive standing, walking and/or sitting.
Lifts, positions and transfers patients with greater than 180lbs weight requirement at times.
Lifts supplies and equipment with weight requirements of approximately 50lbs.
Manual dexterity and mobility, reach with hands and arms, stooping, bending, kneeling and crouching, push/pull, use hands and fingers to touch & feel.
Ability to talk/converse with and be understood by others.
Ability to read, analyze and interpret written information (journal articles, patient records, lab data, etc).
Ability to respond to common inquiries or complaints from customers.
Ability to effectively present information to others (individually or in groups).
Ability to hear alarms on equipment, patient call bell, instructions from physicians and conversations with others.
Far acuity: ability to see clearly at 20 feet or more.
Near acuity: ability to see clearly at 20 inches or less.
Depth perception: ability to accurately judge distance.
Field of Vision: ability to see peripherally.
Accommodation: ability to adjust vision to bring objects into focus.
Color Vision: ability to distinguish and identify different colors.
Answers and converses on the telephone.
Balances figures.
Maintains patient records – both electronically and in paper format.
Computer (Desktop, Portable, and Hand-held devices).
Printers.
Copy Machine.
Fax Machine.
Telephones – Desk and Portable.
Calculators.
Pulse Oximetry Devices.
IV Pumps.
Enteral Feeding Pumps.
Thermometers.
Vital Sign Machines.
Defibrillators.
Cardiac Monitors (Central Stations, Portable Units, Telemetry Units).
Fetal/Vascular Doppler.
Patient Beds.
Fingerstick glucose monitors.
K-Pad.
Bed scales.
Chair Scales.
Standing Scales.
PCA Pumps.
SCD Machines.
Blood Warmer.
Nurse Call System.
Patient lifts.

Nice To Haves

2-4 years experience in nursing.
Previous experience with Case Management, UR, and Transitional Care related duties.
Previous management experience.

Responsibilities

Evaluating patients for admission to the Swing Bed Program and ongoing utilization review of Swing Bed patients.
Performing admission and continued stay reviews on all patients and reporting to utilization management agencies using approved criteria.
Working with the patient, their family, the provider, and other departments and/or outside agencies to facilitate a smooth and safe transition from hospital/transitional care to home.
Providing support to patients and family members during times of crisis as well as acting as liaison between the various healthcare disciplines and the patient and/or patient’s family.
Conduct on-site reviews of potential Transitional Care referrals whenever possible.
Builds and maintains a strong working relationship with the physicians.
Acts as a resource to the physicians, using recognized/appropriate patient care guidelines to assist with care decisions and teaching others how to access and utilize them.
Acts as a resource to the ED physicians and ED staff in determining appropriate patient status (inpatient; observation; etc) for those patients being hospitalized from ED.
Builds and maintains strong working relationships with peers from other facilities, collaborating to achieve and maintain a high swing bed referral rate and promoting the organization's services.
Documents UR/Case Management activities such as precertification, concurrent and retrospective reviews on all patients.
Assesses patient and family needs by reviewing the admission assessment including history and physical and ongoing assessments including safety, infection control, and health education needs.
Utilizes documentation skills to accurately complete patient/unit forms and records.
Intervenes as appropriate in mental and/or physical patient crisis situations (e.g., patient falls, combative behavior).
Consults regularly with other staff and physicians to review treatment plans when level of clinical care requires further clarification.
Assists with training and orienting of new departmental staff as needed, ensuring adequate instruction/training.
Acts as a resource person to the unit staff and provides appropriate and timely feedback concerning their performance.
Works cooperatively with others, showing respect for and understanding of the contributions of all team members.
Assists in maintaining established departmental policies and procedures, objectives, quality improvement program, safety, environmental and infection control standards, ensuring staff compliance.
Assists in maintaining departmental reports and records and collects statistical data for administrative and regulatory purposes.
Assists in implementing unit specific goals and objectives in keeping with overall organizational goals and objectives.
Assists in maintaining adequate and effective communication between physicians, nursing staff, therapy departments, and ancillary departments for problem-solving and improved patient care processes.
Ensures that appropriate care standards and practices are met.
Consults with others as required and adjusts nursing care processes as indicated to ensure optimal patient care and patient outcomes.
Attends required meetings and actively participates on organizational committees.
Promotes professional staff development.
Promotes a safe environment that allows for the delivery of high quality patient care.
Protects patient confidentiality by demonstrating, promoting, and enforcing appropriate staff communication practices.
Ensures practitioner orders are carried out using sound nursing/therapy judgment.
Maintains and utilizes a workable tracking system and clear, concise records for monitoring and reviewing cases.
Prepares documentation/case synopsis upon closure of cases as needed.
Supports and is involved in the hospital’s quality improvement initiative and activities.
Coordinates discharge needs regarding all patients early in the hospitalization.
Provides information to patients and families about types and costs of services available to them to enable them to make informed decisions.
Acts as liaison with nursing/medical staff and community agencies to facilitate problem-solving and coordination of services.
Works with Business Office Personnel regarding authorizations, denials, appeals and retroactive reviews on inpatient, observation and swing beds.
Assesses patient’s needs for intervention by other disciplines (e.g., OT, ST, PT).
Works closely with other disciplines (e.g., OT, ST, PT) to assure patient needs are being met.
Reviews Medicare, Medicaid, private insurance, assigned self-paying patients, and other patients' records whose third-party coverage requires precertification and concurrent monitoring and reporting to designated utilization management agencies to assess medical necessity for hospital level of care and appropriate use of hospital resources.
Reviews all readmissions in an attempt to determine reason for readmission and whether future readmissions are preventable.
Issues Advance Beneficiary Notices according to the Center for Medicare and Medicaid guidelines, when applicable.
Follows appropriate procedure for issuing Termination of Benefits letter when referred case is denied by physician advisor with concurrence of attending physician or by PRO.
Visits all nursing units and abstracts pertinent data from designated medical records. Admission reviews are performed within 24 hours of notification of admission (exclusive of weekends and holidays); extended stay reviews are performed at least by the dates of expiration of the previously assigned length of stay.
Completes monthly statistical reports in a timely manner and submits reports to the appropriate person.
Provides patient/family information when needed on topics related to Medicare, Medicaid, Private Insurance, KCHIP, long term care requirements, etc., acting as a resource.
Acts as a resource to the patient and family concerning Advanced Directives, Guardianship, etc., and assists in accomplishing these.
Demonstrates an understanding of the financial impact to the organization of various components of the Case Manager role, showing a cost-conscious attitude.
Refers questionable cases in which medical record documentation does not support approved criteria to physician advisor members of the UR Committee for a decision regarding justification of medical necessity for admission or continued stay.
Notifies the attending physician of the need for additional documentation in the patient record when criteria are not met on admissions within the required time frame.
Keeps up to date with Medicare, Medicaid, The Joint Commission regulations and requirements along with the pre-certification concurrent review monitoring requirements for the various utilization management agencies/insurance companies.
Ensures that all regulatory guidelines for UR and Transitional Care Program are met and consistently followed.
Delegates appropriately to the Activities Therapist, supervises, monitors, and evaluates their job performance, and notifies them of needed or cancelled visits as census changes.
Performs other duties as assigned.