Job Description

The Nurse Case Manager is responsible for coordinating and facilitating patient care throughout the continuum of care. Working collaboratively with providers, nursing staff, patients, families, payers, and community resources, the Nurse Case Manager promotes safe, efficient, quality, and cost-effective care. Primary responsibilities include care coordination, utilization management, discharge planning, patient advocacy, regulatory compliance, and transition-of-care management. The Nurse Case Manager demonstrates and upholds the Organization's F.I.R.S.T. values of Friendliness, Innovation, Respect, Service, and Trust.

ESSENTIAL FUNCTIONS, DUTIES, AND RESPONSIBILITIES

Care Coordination and Resource Management

1. Assesses patients for discharge planning, transition-of-care needs, and post-acute service requirements.
2. Coordinates care among providers, nursing staff, ancillary departments, patients, families, and external agencies to ensure continuity of care.
3. Identifies barriers to care for progression and discharge and implements interventions to facilitate timely resolution.
4. Participates in interdisciplinary rounds, patient care conferences, and care planning activities.
5. Facilitates evidence-based care delivery and appropriate utilization of healthcare resources to support optimal patient outcomes.

Utilization Management and Length of Stay Oversight

1. Performs admission, concurrent, and continued stay reviews using approved medical necessity criteria and payer guidelines.
2. Reviews admission status and level-of-care determinations to ensure appropriate patient classification.
3. Collaborates with providers and Physician Advisors regarding medical necessity, admission status, documentation requirements, and level-of-care concerns.
4. Escalates cases that do not meet established criteria for Physician Advisor review and recommendation.
5. Monitors avoidable days, identifies barriers to discharge, and implements strategies to improve patient throughput and optimize length of stay.

Discharge Planning and Transition Management

1. Conducts comprehensive discharge planning assessments in collaboration with the discharge planner and interdisciplinary team.
2. Coordinates referrals and arrangements for post-acute services, including but not limited to: Home Health Services, Skilled Nursing Facilities (SNF), Inpatient Rehabilitation Facilities (IRF), Long-Term Acute Care Hospitals (LTACH), Durable Medical Equipment (DME), Hospice and Palliative Care Services
3. Ensures patients and families are provided freedom of choice regarding post-acute providers in accordance with regulatory requirements.
4. Facilitates safe, timely, and effective patient discharges.

Patient and Family Education

1. Educates patients and families regarding discharge plans, available resources, insurance benefits, and care transitions.
2. Promotes patient participation in care planning and advocates patient preferences while balancing clinical and payer requirements.
3. Provides education regarding community resources and post-discharge support services.

Regulatory Compliance and Documentation

1. Ensures compliance with CMS Conditions of Participation, Medicare regulations, Medicaid requirements, and payer guidelines.
2. Delivers and documents required patient notices, including but not limited to: Important Medicare Message (IMM) Medicare Outpatient Observation Notice (MOON)
3. Maintains accurate, timely, and complete documentation within the electronic medical record.
4. Participates in audits, surveys, and compliance reviews as assigned.

Communication and Collaboration

1. Communicates effectively and professionally with patients, families, providers, payers, and interdisciplinary team members.
2. Promotes teamwork and collaboration to achieve positive patient outcomes.
3. Maintains professionalism and composure during challenging situations.
4. Serves as a positive role model and supports organizational initiatives, goals, and performance improvement activities.
5. Professional Accountability and Quality Improvement
6. Demonstrates professional, ethical, and clinical accountability in all aspects of practice.
7. Maintains and expands professional knowledge and competencies related to case management and care coordination.
8. Participates in quality improvement initiatives designed to enhance patient outcomes, resource utilization, throughput, and care coordination.
9. Identifies opportunities to improve efficiency, reduce costs, and enhance the patient experience while maintaining quality standards.
10. Participates in onboarding, mentoring, and educational activities as appropriate.

WORKING CONDITIONS, HAZARDS, AND PHYSICAL EFFORT

Primarily light work requiring the ability to move or position up to 10 pounds. Requires prolonged periods of sitting, standing, walking, and computer use. Works primarily in a climate-controlled office environment but is required to visit patient care areas and other departments for patient assessments, care coordination, meetings, and related activities.

CONTACT WITH OTHERS

Frequent interaction with physicians, nursing staff, department leaders, ancillary departments, patients, families, payers, Physician Advisors, utilization review personnel, community agencies, post-acute providers, and referral sources.

EQUIPMENT USED / SPECIAL SKILLS REQUIRED

• Proficient computer and electronic medical record (EMR) skills.
• Preferred knowledge of Meditech or equivalent healthcare information systems.
• Knowledge of medical terminology, diagnoses, payer requirements, and medical necessity criteria.
• Strong organizational, critical thinking, communication, and interpersonal skills.
• Ability to effectively collaborate with physicians, healthcare professionals, community agencies, and insurance representatives.

Qualifications

Minimum of three (3) years of healthcare experience required. Previous experience in case management, utilization review, discharge planning, or care coordination preferred.

Location

Ephraim McDowell Regional Medical Center, Inc.

Education Required

Graduate of an accredited school of nursing.

Certification Required

Current and unrestricted Kentucky Nursing License (RN) (LPN). Case Management certification (CCM, ACM, or equivalent) preferred.

Other Shift

Weekends

Compensation:

$26.85 - $42.67 Based on Experience. 5% weekend shift diff.