Job Description

The Case Manager will facilitate the interdisciplinary plan of care with a focus on evaluating the appropriateness of clinical care, medical necessity, admission status, level of care, and resource management. The Case Manager will coordinate activities that promote quality outcomes and patient throughput while supporting a balance of optimal care and appropriate resource utilization. The Case Manager will identify potential barriers to patient throughput and quality outcomes. The Case Manager will facilitate appropriate discharge plans.

1. Case Management
   1. Demonstrates the ability to maximize financial outcomes of assigned patient load using the continuum of care philosophy. Assists in the development, monitoring and analysis of annual financial goals of targeted population.
   2. Performs effective utilization review techniques to work with physicians, third party payors and federal and local agencies to prevent denials of payment and days.
   3. Acts as a resource for unit personnel in the resolution of utilization/case management problems and expediently communicates identified problems to appropriate personnel in an effort to enhance departmental operating efficiency.
   4. Evaluates the quality of necessary medical services, utilizes criteria to determine medical necessity of admissions and interacts with physicians to facilitate patient assignment to appropriate alternative of care. Understands the capabilities of outside referral sources such as home health, sub-acute care and skilled nursing facilities.
   5. Understands the different types of healthcare delivery systems and the requirements for prior approval by payor for admissions, procedures and continued stay.
   6. Meets with treatment team to provide utilization review information, discusses issues pertaining to continued stay, discharge and aftercare plans, evaluates current financial resources, and discusses whether documentation reflects the need for continued stay and at what level of care is most appropriate.
   7. Provides appropriate and timely information to third party payors to facilitate financial outcomes and ensures patients are receiving appropriate level of care; includes coordinating denials/appeals.
   8. Collaborates with all members of the health care team to ensure reimbursement optimization, appropriate discharge planning and cost-effective quality care. Plays a key role in the discharge planning process assessing patients' needs for referrals and/or alternate levels of care. Appropriately tracks and report avoidable days.
   9. Demonstrates ability to access and utilize community resources. Knows how to establish a client support system.
   10. Demonstrates competence in coordination and service delivery. Understands methods for assessing an individual's level of physical/mental impairment. Assesses patient clinical information and in collaboration with the healthcare team develops treatment/discharge plans.
   11. Strives to promote the quality and efficiency of his/her own performance by remaining current with the latest trends in field.
   12. Promotes concurrent DRG/documentation management via feedback and education to physicians regarding appropriated documentation that reflects patient acuity and resource utilization.
2. Other Duties as Assigned
   1. Good interpersonal/human relations skills
   2. Good oral and written communication skills.
   3. Good problem solving and critical thinking skills
   4. Good time management/prioritization skills.
   5. Performs other duties as assigned or requested.
   6. Consistently performs 12 organizational Service Standards focused on Values, Service and Quality.

Experience - 3 years clinical experience

Education - Graduate from Accredited RN Program