RN Care Manager -PSMC

Phoebe Putney Health System•Sumter, SC

13d

About The Position

The Nurse Case Manager (Care Manager) coordinates patient care from entry through discharge for patients receiving inpatient and observation services at PPHS facilities. The role addresses appropriate and timely admission, discharge, and care; performs clinical reviews using hospital-approved criteria and the Care Management Program’s Utilization Plan and payer requirements; and supports efficient care at the appropriate level. The Care Manager collaborates with social work, physicians, nurses, and the interdisciplinary team to provide quality, timely, and cost-effective case management, facilitate patient progression through a defined plan of care, and address readmission issues. Under the direction of the Care Management Team Lead and Director of Care Management, the Care Manager develops, facilitates, and implements case management and discharge plans. The position performs utilization review and discharge or transition planning, assesses patient and family needs, coordinates care across acute and post-acute settings, identifies delays and risks, and documents reviews, referrals, activities, and outcomes in the appropriate electronic system. The Care Manager also educates patients, families, physicians, nurses, and other staff about care management processes and transition options, participates in performance improvement, and supports safe, timely patient outcomes.

Requirements

Associate’s Degree in Nursing from a state-accredited school.
At least 1 year of recent acute care experience with relevant clinical experience in the assigned area.
Registered Nurse (RN) with a current Georgia license.
Ability to apply current federal, state, accreditation, payer, and regulatory requirements relevant to utilization review and discharge planning.
Ability to perform care management assessments, clinical reviews, coordination, discharge planning, and accurate electronic documentation.

Nice To Haves

Bachelor’s Degree in Nursing from a state-accredited school.
At least 1 year of case management or utilization review experience in a hospital or related setting.
Certified Case Manager certification upon hire.

Responsibilities

Coordinate patient care from point of entry through discharge for inpatient and observation patients.
Perform prospective or concurrent utilization reviews, and retrospective reviews when required, using established clinical criteria and payer and regulatory requirements.
Support appropriate admission, continued stay, level of care, and timely discharge while helping maintain compliance, protect patient rights, and avert denials or patient liability.
Develop and facilitate individualized case management, care, and discharge or transition plans in coordination with physicians, nursing, social work, and the interdisciplinary team.
Assess patient and family clinical, emotional, cultural, psychosocial, treatment, care-option, and financial needs; identify risk factors and make timely referrals.
Educate patients and families about discharge services, options, providers, payer authorizations, and actions needed to meet financial obligations for transition planning.
Educate physicians, nurses, and other hospital personnel about care management processes and payer or regulatory policies.
Identify actual or potential delays in care and intervene with physicians, nursing, and other departments to promote timely services and prevent quality, medical-necessity, payment, or authorization issues.
Coordinate care among caregivers and across acute and post-acute settings, engaging patients and legally appropriate representatives in planning and decisions.
Monitor and reassess patient and family needs, evaluate plans and outcomes, and document evaluation results.
Escalate physician, patient-care, or quality issues to the Physician Adviser designee or Chief Utilization Officer as needed, and seek guidance from the Team Lead or Director.
Assess readmission patterns, trends, and root causes; collaborate with relevant disciplines to address patient-specific issues and help prevent future readmissions.
Participate in quality improvement, committees, projects, and professional activities; incorporate evidence-based knowledge and support improvements to care coordination, patient flow, and hospital efficiency.
Document review activity, follow-up, referrals, transition-planning activities, and outcomes accurately and promptly in the appropriate electronic system.
Maintain current knowledge and competencies, attend staff meetings and mandatory training, follow attendance and departmental policies, and perform other assigned duties.