Registered Nurse Case Manager Lead (RN)

Conifer Health Solutions • Phoenix, AZ

4d

About The Position

Position Summary The position manages the continuum of care for assigned patients and serves as the content expert and role model for department staff. The Lead Case Manager serves as the expert in all aspects of the role including care coordination, collaboration and facilitation, advocacy for patients and families, discharge planning and utilization review. The position serves as the department expert aka "Super User" of MIDAS, CERMe, Curaspan, Portal and MS4. The Lead Case Manager has the primary responsibility for training new staff and providing education to all department staff when new initiatives are implemented. The position provides initial and annual InterQual training for RN Case Managers.

Requirements

• Education: Nursing Degree from an Accredited Nursing School.
• MIDAS, CuraSpan and InterQual Certified Instructor (IQCI) training with proficiency testing
• Experience: Minimum of 3 years acute care hospital experience required and 2 years recent acute care hospital case management, discharge planning and utilization management experience.
• Licensure/Certifications: Current Registered Nurse Licensed in the State of Arizona
• Special Skills: The critical knowledge base of nursing process, continuum of care and case management methods and standards, excellent communication and documentation skills. Demonstrates knowledge of Age-Specific Criteria, American Nurses Association (ANA) Nursing Scope and Standards of Practice, ANA Code of Ethics for Nurses, Arizona Nurse Practice Act, Core Measures and American Case Management Association (ACMA) Case Management Standards of Practice.

Nice To Haves

• Education: Bachelor of Science in Nursing
• Experience: 3-5 years experience in acute care hospital Case Management, Utilization Management and Discharge Planning and 1 year hospital supervisory experience. Public speaking and adult education experience preferred.
• Certification/Registrations: Certified Case Manager, CCM or Accredited Case Manager, ACM.

Responsibilities

• Discharge Planning - Utilize the nursing process to conduct a thorough assessment of discharge needs beginning at admission and as care needs evolve to assure a seamless and safe patient transition to the most appropriate level of care that has the identified resources to meet the medical, nursing and psychosocial needs of the patient. The RN Case Manager works with the physician who is the decisive authority in the referral, transfer or discharge of his/her patient to another level of care. The RN Case Manager collaborates with the interdisciplinary team to implement the identified discharge plan. Accountability / Responsibility: Develops and effectively utilizes a network of information regarding community resources Coordinates the discharge planning process in collaboration with social workers and/or other professional members of the interdisciplinary team. Appropriately delegates within the scope of practice discharge planning activities / functions and supervises others involved with discharge planning including LPNs, Case Management Coordinators or other non-licensed personnel performing discharge planning activities. Identifies the appropriate post hospitalization care and services required. Develops post hospital plan of care with the patient and / or family, physician and external resources. Communicates and documents discharge planning needs. I nitiates appropriate and timely social services, palliative care or other specialty referrals. Provides necessary patient teaching relevant to discharge needs, post hospital care arrangements prior to discharge. Assesses the patient prior to discharge to determine if the plan is appropriate and makes necessary revisions. Keeps the interdisciplinary care team informed re: details of the discharge plan including printing updated Midas notes and placing on chart. Communicates essential information to the next care provider as described in the hospital discharge planning policy. Educates patient regarding their Medicare appeal rights and initiates the Detailed Notice of Discharge (DND) when the patient decides to appeal their discharge. Contacts the Quality Improvement Organization (QIO) per established protocol detailed in the Hospital Issued Notice of Non-Coverate (HINN).
• Utilization Review. Consistently applies the utilization review process as required by the Code of Federal Regulations including the use of Abrazo designated criteria for primary review. Incorporates into the utilization review process the ability to access and interpret clinical information against the designated review criteria to reach correct admission status determinations. Has the current knowledge of applicable regulations and laws pertaining to the major payers including Medicare, Medicaid, and other payers. Works with the interdisciplinary team to ensure that the care and services provided are medically necessary, cost effective, delivered efficiently and timely, and at the appropriate level of care to meet payer requirements and established financial/performance benchmarks for the facility and Abrazo. Accountability/Responsibility: Coordinates internal and external services to avoid under or over utilization of resources. Indicates the working DRG in MIDAS or other tools. Facilitates or participates in interdisciplinary team meetings or rounds. Reviews record including physician orders and documents admission, concurrent discharge reviews and retrospective reviews as assigned. Communicates with physicians regarding the level of care or admission status when appropriate criteria are not met for inpatient, observation or continued stay. Refers cases to Physician Advisor according to policy and documents the referral. Reviews Observation status patients within 16 hours of admission and obtains appropriate orders based on patients’ clinical condition. Notifies admissions office of errors/changes in patient data including changes in physician orders/incorrect admission status designation. Identifies and documents avoidable days and denials. Initiates the appropriate letter (HINN: admission or continued stay, ABN) for any Medicare beneficiary if the outcome of the Physician Advisor secondary review indicates that the patient does not meet inpatient admission/observation status or continued stay medical necessity criteria. Provides and documents concurrent reviews or other information requested by the payer within required timeframes. Documents insurance authorizations received in Midas or on the UM Worksheet

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree