Promotes the development of high quality patient care in the most effective setting, balancing patient/hospital advocacy. Knowledgeable of third party payor issues.
Coordinates patient care across the continuum of care:
- As needed, strives to maximize and mobilize all internal and external resources that facilitate the case management process for all assigned cases
- Documentation always reflects patient plan of past hospital care and if applicable interdisciplinary coordination.
- As needed, provides a nursing assessment within 24-48 hours of patient admission for clinically oriented services focused on mobilizing primary care physician, hospital systems, patient/family and community resources directed towards facilitating a clinically safe and timely discharge
- Identifies problems and gaps in patient care when covering for unit case manager. Suggested interventions, expedited interdisciplinary referrals and ensured diagnostic testing is completed and reported within appropriate timeframe
- Actively participates in patient care conferences as scheduled on nursing units when covering for the unit case manager
- Works collaboratively with medical staff, nursing and other therapeutic disciplines in developing and implementing a patient plan of care while covering for case manager. Follows plan of care initiated by unit case manager. Initiates initial plan of care for new patients assigned.
- Clinically documents patient plan of care, progress, goals, and interventions according to Case Management Department, Federal, and State guidelines.
- Maintains a professional working relationship with Managed Care Organization telephonic and on site reviewers and external reviewing agencies in monitoring course of hospitalization and need for post hospital services according to third party payor guidelines. Returns all calls from managed care organizations occurring on day covering the case.
- Community health care agencies and third party payor utilization review agencies are provided with patient care information through allscripts that is concise, accurate and communicated in a timely manner. All reviews assigned to per diem case manager sent when completed unless review referred for second level review.
Monitors utilization of resources:
- Exercises professional authority intervening when necessary with physicians /therapeutic disciplines to remove barriers that impact length of stay. Communicates via allscripts to unit case manager any issues identified while covering unit
- Always demonstrates awareness of over or under utilization of resources and responds accordingly
- Appropriately monitors utilization of resources for caseload assigned
- Demonstrates understanding and has accurately applied severity of illness/intensity of service criteria according to third party payor guidelines, appropriately identifying levels of care for all assigned cases.
- Maintains ongoing dialogue with medical staff, nursing and other involved therapeutic disciplines relative to utilization and length of stay issues and communicates via Allscripts to unit case manager
- Demonstrates initiative in exploring strategies to reduce length of stay and resource consumption within complex case managed patient populations.
- Effectively identifies patients for complex management versus those patients with less significant needs
- Communicates with other members of healthcare team regarding patients’ needs, plan and response to care
- As needed, offers assistance/solutions to physicians in resolving external third party payor issues
Negotiates, procures, and coordinates service and resource:
- Based on third party payor criteria, always works with patients/families/physicians to effect a positive length of stay outcome
- Always demonstrates critical thinking and sound clinical judgment in matters of patient advocacy versus conflict with the third party payor requirements
- Establishes patient/family contact within the timeline required by department policy and explains case management role.
- Identifies with patient/family expected length of stay and planned outcomes throughout the episode of acute hospitalizations
- Demonstrates a working knowledge of the resources available in the community for patients/families
- Ensures through coordination and collaboration with primary care physician and nursing that appropriate hospital services maximizing patient independence is initiated
- Expeditiously and appropriately identifies and refers those patients in need of short term skilled/long term chronic care
- Manages each patient’s transitions through the systems and transfers accountability to the systems and transfers accountability to the appropriate person or agency upon discharge
- Always reports issues of quality care to Outcomes Manager when covering cases
- Participates in data collections processes for monitoring and tracking resource utilization and outlier stays, identifying consistent aberrant practices.
- Collects, organizes, and inputs data according to QRM quality indicators, quality screens and case management criteria
- Demonstrates initiative and creativity in developing and implementing strategies for addressing and resolving patterns or issues that have a negative quality-cost impact appropriate person or agency upon discharge
Assists in meeting department goals:
- Seeks opportunities outside the hospital system to improve on knowledge base and skills in case management
- Demonstrates self-motivation and leadership in achieving the goals of case management
- Demonstrates willingness to assume new responsibilities as requested
- Attends department meetings when available and actively participates in discussion and resolution issues
- Informs department secretary of any interchange of/or new referrals received so as to ensure accuracy of statistical data maintained in the department
- Keeps abreast of federal, state guidelines that relate to utilization management and discharge planning regulations and demonstrates accountability and responsibility for adhering to case management policies and procedures
- Assumes responsibility for covering case management activities in the absence of assigned case manager
- Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
1. Commits to recognize and respect cultural diversity for all customers (internal and external).
2. Communicates effectively with internal and external customers with respect of differences in cultures, values, beliefs and ages, utilizing interpreters when needed.
Performs other duties as assigned
REQUIRED KNOWLEDGE & SKILLS
- Basic computer literacy
- Knowledge of disease management
- Education: Bachelor of Nursing Degree required. Significant Case Management experience considered in lieu of Bachelor degree.
- Experience: Three to five years experience acute care nursing experience or one to three years experience in utilization review and/or discharge planning preferred
- Certification/Licensure: Current MA RN license
Equal Opportunity Employer
Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.
Important COVID message
Please note, Saint Anne’s Hospital is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment - with confidence and without fear. Our Safe and Ready program consists of a rigorous [five-point] standard ensuring patient safety, confidence and convenience: Expanded hours will allow previously cancelled procedures to be scheduled as quickly as possible. Any COVID-19 related care takes place in designated areas away from other patients and their families. Emergency Departments are reorganized to be a safe place to treat all emergency patients. A stringent cleaning policy has been implemented throughout the hospital. A strictly controlled visitor and masking policy is required for patient safety. You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.