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Case Manager II - BSN - Days
A Case Manager II (CM II) comprehensively plans for case management of a targeted patient population on a designated unit(s). Works with the physicians and multidisciplinary care team to facilitate efficient quality care and achievement of desired treatment outcomes. Holds joint accountability with social worker for discharge planning and continuity of care. Assures that admission and continued stay are medically necessary and communicates clinical information to payers to ensure reimbursement.
PATIENT AGE GROUP SERVED
Describe the age group of primary customers/patients served if applicable to this position.
Not applicable School Age (6-12 years)
Neonate (Birth to 28 days) Adolescence (12-18 years)
Infants/Toddlers (29 days to 18 months) Young Adult (19-40 Years)
Toddler (18 months to 3 years) Middle Adult (40-65 Years)
Preschooler (3-6 years) Mature Adult (65 years and older)
System and department specific ICARE values
INTEGRITY: We are honest and ethical in all we say and do.
COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
ACCOUNTABILITY: We hold ourselves accountable for all our actions.
RESPECT: We treat every individual as a person of worth, dignity, and value.
EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.
Duties and Responsibilities are cross-referenced to the hospital's Pillars of Excellence and will be transferred to Performance Evaluation. Please include % breakout of tasks/essential functions.
1. Identifies leadership opportunities for professional growth of peers. (People)
2. Communicates in an active, positive and effective manner to all health care team members and reports pertinent patient care and family data in a comprehensive and unbiased manner, listens and responds to the ideas of others. (People)
3. Implements staff education specific to patient populations and unit processes; coaches and mentors other staff and students. May include preceptorship. (People)
4. Uses downtime efficiently, aware of team members' workload, consistently offers assistance, and responds positively to requests for assistance from other team members. (People)
1. Contributes to meeting departmental financial target on scorecard, with focus on length of stay. (Finance)
2. Secures reimbursement for hospital services by communicating medical information required by all external review entities, managed care contracts, insurers, fiscal intermediaries, and state and federal agencies. Responds to requests for information, monitors covered days, and initiates review to assure that all days are covered and reimbursable. (Finance)
3. Manages all patients in Observation Status, daily, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital. (Finance)
1. Modifies care based on continuous evaluation of the patient's condition, demonstrates clinical problem-solving and critical thinking, and makes decisions using evidence-based analytical approach. (Quality/Safety)
2. Plans for routine discharge and anticipates/prevents and manages/elevates emergent situations. Specific focus given to discharge plan and elimination of barriers. (Quality/Safety)
3. Contributes to meeting departmental targets for quality and safety measures on scorecard. (Quality/Safety)
4. Uses a structured format for regular communication with patients and families.. (Quality/Safety)
5. Manages usual patient assignment and other unit demands, completes responsibilities in timely manner with accurate documentation, organizes multiple priorities and anticipates/plans for potential problems. (Quality/Safety)
6. Reports near misses as well as errors promptly and consistently to improve systems and processes and identify trends. (Quality/Safety)
7. Collaborates with staff from the interdisciplinary team concerning safety data to improve outcomes and the safe transition of care through effective patient handoffs. (Quality/Safety)
8. Implements unit and hospital initiatives to achieve National Patient Safety Goals. (Quality/Safety)
9. Identifies opportunity for practice changes. Researches the change and presents options to shared governance and leadership. (Quality/Safety)
10. Assures that designated core measures are met in providing care. (Quality/Safety)
1. Maintains individual competencies around critical Case Management functions including; payer rules and regulations, evidence-based level of care criteria sets, and assessment and discharge planning methods. (Service)
2. Serves as a unit-based leader for comprehensive case management activities including assessing all patients and leading team to set discharge plan, participating in daily Care Coordination Rounds, and identifying and leading resolution to barriers of efficient patient throughput.(Service)
3. Uses clinical expertise and high risk screening tools to identify need for case management and/or social work intervention. Screening is accomplished by patient/family interview, review of the medical record including previous episodes of care, H&P, lab and other test results/findings, plan of care, physician orders, nursing and progress notes. (Service)
4. Completes full assessment based on the case management high-risk screening tool. (Service)
5. Continuously reviews the total picture of the patient for opportunities for care facilitation and needs for discharge planning. (Service)
6. Applies approved utilization criteria to monitor appropriateness of admissions, level of care, resource utilization, and continued stay. (Service)
7. Documentation should reflect, completed patient screening/assessment and reassessment upon admission and concurrently as needed. This should be documented in MethOD. (Service)
8. Facilitates discharge planning activities for assigned patients and collaborates with the social worker and other members of the interdisciplinary team, as well as patient and family, on complex discharges. Maintains ownership of the discharge planning process on assigned units. (Service)
9. Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care and program compliance using InterQual Hospital Severity of Illness and Intensity of Service Criteria or Milliman Care Guidelines. Standard for initial review is within 24 hours of entry or next working day. Standard for concurrent clinical reviews is every 48 hours and no more than 72 hours. (Service)
10. Denial management: identifies when services no longer meet InterQual/ Millman l criteria, initiates discussion with attending physicians, coordinates with the external case manager to facilitate discharge planning, seeks assistance from the physician advisor, if needed, informs supervisor of the possible need for issuing Medicare Hospital Initiated Notice of Non-coverage. (Service)
11. Establishes mutual educational goals with patient and family, provides appropriate resources, incorporating planning for care after discharge. (Service)
12. Supports patients and families in preventing/resolving clinical or ethical issues. (Service)
13. Contributes to meeting target for patient satisfaction on scorecard, with focus on discharge domain. (Service)
14. Uses knowledge of levels of care to ensure discharge disposition is to the appropriate level and facilitates transfers. Initiates and facilitates referrals for home health care, hospice, and durable medical equipment. Consults Social Worker to assess psychosocial needs associated with transition to alternative levels of care. (Service)
15. Uses therapeutic communication to establish a relationship with patients and families and communicates the discharge plan. (Service)
1. Provides education to unit-based physicians,