RN Case Manager

Beloit Health System•Beloit, WI

About The Position

Beloit Health System is looking to add an RN Case Manager to our Care Coordination Team! The RN Case Manager (CM) will complete utilization review responsibilities and assist with coordinating the patient transition of care from admission to discharge. The patient population will include those with complex medical conditions, and/or social-economic and mental health co-morbidities. The CM will be an active member of the collaborative team consisting of the patient, nurses, social workers, physicians, other providers, family, and caregivers. The CM goal is to ensure quality, timely, and cost-effective care of the patient during their hospitalization. Assist with assessing the physical, functional, social, psychological, environmental, learning and financial needs of the patient as appropriate. Identify problems, goals and interventions to meet the patient's needs. Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served. Evaluate patient's progress toward discharge goal including identification and evaluation of barriers to meeting or complying with plan of care. Participates in multi-disciplinary discharge rounds and care conferences to ensure appropriate and timely discharge of patients. Effectively communicates to the comprehensive care team the level of care needed based on medical necessity using hospital approved guidelines. Provide education, information, direction, and support related to patient care goals and discharge plan. Identify patients that are at risk for readmission and work with the care team to ensure patient needs and follow-up care is in place to minimize the potential for readmission. Work with the transition of care nurse to follow patients identified as high risk for readmission for 30 days post discharge Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan. Coordinate care and treatment plans between providers. Facilitate communication between providers and departments as necessary to ensure timely care and cost-effective utilization of resources. Determination of appropriate admission status (inpatient, observation, outpatient in a bed) using hospital approved guidelines. Concurrent reviews of admissions/observations for monitoring of medical necessity for hospital stay using hospital approved guidelines. Discuss with physicians any concerns regarding utilization of services, level of care, medical necessity, LOS, and documentation requirements. Consult physician advisor (Director of Hospitalists and department heads) regarding admissions that do not meet hospital approved guidelines/criteria and the admitting or attending physician disagrees. Completes initial and continued stay insurance reviews as requested by the payers for certification of coverage. Manages denials related to lack of medical necessity as determined by the payer including, but not limited to, setting up Peer to Peer review and written appeals. Identifies quality issues and reports to leadership of quality department. Participate in prospective, concurrent and retrospective case reviews as requested. Use hospital approved guidelines to educate physicians and nursing staff on optimal care for hospital admissions and readmissions. Maintain accurate patient records and patient confidentiality. Documentation will meet requirements for audits and QI report needs. Identify patient complaints/issues and direct appropriately (Is knowledgeable of HCAHPS survey questions). Attend mandatory training sessions and staff meetings as assigned. Develop, implement, and evaluate department initiatives and goals as assigned. Assist with the collection, analysis, benchmarking and reporting of data. Collaborate in the development of policies, protocols, and guidelines for the case management program. Promote the case management program to care providers.

Requirements

Current WI RN license
Minimum of 2 years' acute care hospital experience
Excellent observation, organizational, verbal and written communication skills
Ability to solve problems quickly while under time constraints
Ability to be flexible with schedule to efficiently and effectively manage case load
CPR Certification within 90 days
Adheres to established Health System and Care Coordination department policies, rules and regulations
Maintains ethical conduct and keeps confidential personal and medical information about patients

Responsibilities

Complete utilization review responsibilities
Assist with coordinating the patient transition of care from admission to discharge
Ensure quality, timely, and cost-effective care of the patient during their hospitalization
Assist with assessing the physical, functional, social, psychological, environmental, learning and financial needs of the patient as appropriate
Identify problems, goals and interventions to meet the patient's needs
Provide appropriate interventions which demonstrate knowledge of and sensitivity toward cultural diversity and religious, developmental, health literacy, and educational backgrounds of the population served
Evaluate patient's progress toward discharge goal including identification and evaluation of barriers to meeting or complying with plan of care
Participates in multi-disciplinary discharge rounds and care conferences to ensure appropriate and timely discharge of patients
Effectively communicates to the comprehensive care team the level of care needed based on medical necessity using hospital approved guidelines
Provide education, information, direction, and support related to patient care goals and discharge plan
Identify patients that are at risk for readmission and work with the care team to ensure patient needs and follow-up care is in place to minimize the potential for readmission
Work with the transition of care nurse to follow patients identified as high risk for readmission for 30 days post discharge
Act as a patient advocate and assist with problem solving and addressing any barriers to care or compliance with care plan
Coordinate care and treatment plans between providers
Facilitate communication between providers and departments as necessary to ensure timely care and cost-effective utilization of resources
Determination of appropriate admission status (inpatient, observation, outpatient in a bed) using hospital approved guidelines
Concurrent reviews of admissions/observations for monitoring of medical necessity for hospital stay using hospital approved guidelines
Discuss with physicians any concerns regarding utilization of services, level of care, medical necessity, LOS, and documentation requirements
Consult physician advisor (Director of Hospitalists and department heads) regarding admissions that do not meet hospital approved guidelines/criteria and the admitting or attending physician disagrees
Completes initial and continued stay insurance reviews as requested by the payers for certification of coverage
Manages denials related to lack of medical necessity as determined by the payer including, but not limited to, setting up Peer to Peer review and written appeals
Identifies quality issues and reports to leadership of quality department
Participate in prospective, concurrent and retrospective case reviews as requested
Use hospital approved guidelines to educate physicians and nursing staff on optimal care for hospital admissions and readmissions
Maintain accurate patient records and patient confidentiality
Documentation will meet requirements for audits and QI report needs
Identify patient complaints/issues and direct appropriately (Is knowledgeable of HCAHPS survey questions)
Attend mandatory training sessions and staff meetings as assigned
Develop, implement, and evaluate department initiatives and goals as assigned
Assist with the collection, analysis, benchmarking and reporting of data
Collaborate in the development of policies, protocols, and guidelines for the case management program
Promote the case management program to care providers