RN CASE MANAGER (REG) 8/10/2016
JOB DESCRIPTIONAPPLY The RN Case Manager (CM) facilitates the coordination of care for patients admitted to Medical, Surgical, Pediatric or Obstetrical Services and as needed for hospital outpatient areas including but not limited to the Emergency Department and Henderson Surgical Center. The CM may also oversee the coordination of care both inpatient and outpatient for those patients identified as at high risk for readmission. The CM will develop and implement discharge plans for those patients identified as needing post acute discharge services or post acute follow up in collaboration with the patient/legal representative, health care team/provider, insurer and others including community based organizations as needed. The CM uses a collaborative process of assessment, planning, facilitation and advocacy. Additionally, she/he may use a high risk screening criteria or other acceptable screening tools to determine what patients may benefit from specialized care coordination services. The CM consults and collaborates with physicians regarding medical necessity of admissions and appropriate level of care for hospitalized patients utilizing nationally accepted criteria. He/she routinely reviews patients health records and communicates with the health care team/provider to ensure continued appropriate level of care, compliance with Federal and State regulations related to discharge planning, compliance with CMS regulations or other third party payers and appropriate utilization of hospital and medical resources. The CM completes timely and accurate insurance reviews as requested by third party payers. The CM will serve as a resource for physicians, hospital staff and patients and their families in providing information about insurance coverage, limitations of coverage related to discharge planning, community resources, community referrals and post acute care options. He/she participates in quality and risk management case finding activities. The role requires the ability to offer creative, problem solving techniques using sound and prudent clinical judgment and within the scope of licensure and according to case management standards of practice. The CM seeks out educational and self development opportunities related to care coordination, transitions of care, healthcare reimbursement and other pertinent areas.
Case Management process:
Patient identification and selection: Focuses on identifying patients who would benefit from case management services.
Assessment and problem/opportunity identification.
Development of the care coordination plan: Establishes goals of the intervention and prioritizes the patients needs, as well as determines the type of services and resources that are available in order to address the established goals or desired outcomes.
Implementation and care coordination plan.
Evaluation of the plan and follow-up.
Identifies patients who may require post discharge services utilizing high risk screening criteria, referrals or other available resources.
Performs assessment of patient discharge planning needs based upon medical condition including previous history, functional status, psycho social support, living situation and previous post discharge or homecare services.
Includes patient and/or family in the discharge planning process through verbal and written communication.
Facilitates safe, effective and efficient discharge plans in collaboration with the patient, the family, the attending and/or primary care physician, nursing staff, other appropriate clinical staff, third party payers and/or community based care coordinators or other appropriate outside agencies,
Conducts ongoing assessment of the patients health status, ensuring the patient is appropriate for the services/care provided and revising the post acute plan as needed.
Ensures the implementation of the discharge plan including making facility/agency referrals and determining availability of services.
Ensures whenever possible, third party payer approval of services needed
for post acute care.
Acts as consultant to physicians and hospital staff regarding resources,
regulations and reimbursement.
Documents the assessment, plan, and ongoing notes as part of the health
record according to hospital and departmental policy.
Completes the case management sections of necessary discharge paperwork.
Facilitates the paperwork sent to post discharge service providers with the goal of improving transitions of care.
Participates in the planning, implementation, monitoring, and follow-up of patients either prior to or following hospital episode of care in collaboration with external healthcare providers including Primary Care Physicians as well as community based organization.
Provides expert guidance to the medical, nursing and rehab staff as well as other Hospital departments regarding Hospital criteria, insurance regulations, care coordination efforts, and discharge planning activities.
Performs admission and concurrent utilization management using Hospital approved criteria as a guide for determination of appropriate level of care.
Completes accurate insurance utilization reviews and obtains third party payer approval of services needed for post-hospital care as needed.
Identifies utilization management issues, analyzes, documents and reports appropriately in accordance with hospital and departmental policies and procedures.
Identifies and intervenes in service delays and inappropriate utilization of health care resources utilizing clinical knowledge, experience, accepted Clinical Practice Guidelines.
Identifies patients at high risk for readmission and implements enhanced care practices and or other interventions.
Identifies methods to reduce readmissions including increased oversight and communication with patients and providers in the community setting.
Participates in medical/utilization management activities for those patients whose health plan has delegated medical management to the Newton Wellesley Physician Hospital Organization.
Refers appropriate cases to the Physician Advisor, Physician Hospital Organization Medical Directors and/or Department or Service Chiefs or Senior VP for Medical Affairs in accordance with departmental policies and procedures.
As delegated by Medicare or other third party payers, delivers notices of
Non-coverage and/or proposed insurance denials to patients/families according to payer, Hospital and departmental regulations/policies.
Quality /Performance Improvement
Participates in performance improvement measurements and initiatives including identification of variances/delays.
Participates in inter-departmental committees, focus groups, task force or other special projects as requested.
Identifies quality of care issues, analyzes, documents and reports appropriately in accordance with Hospital and departmental policies and procedures.
Regulatory compliance and JCAHO accreditation
Demonstrates understanding and compliance with applicable standards e.g. discharge and other standards as required.
Participates in on site visits or mock surveys.
Takes responsibility for updating ones knowledge of the National Patient Safety Goals and other patient care related JCAHO standards.
Demonstrates knowledgeable about government regulations related to patient rights, confidentiality, and discharge planning.
Participates in special projects such as audits, policy and program development, and other such duties as directed.
Participates and/or carries out other duties as assigned or requested.
Graduate of an accredited school of nursing. BSN preferred.
Current licensure as a Registered Nurse in the Commonwealth of
Massachusetts, with minimum of three years clinical experience, excellent