Job Description

The Case Manager functions as the primary liaison between North Texas Medical Center, patients treated in the Emergency Department, the Intensive Care Unit, the Women’s Center unit and families, the physician, the payer, community partners and all other related parties to ensure appropriate level of care by comprehensive review of medical necessity of outpatient observation and inpatient stays. The position champions placement of the patient in the right status with appropriate and efficient resource utilization.

OF ESSENTIAL JOB FUNCTIONS

• Reviews admissions and continued stays, determining the necessity and appropriateness of hospitalization, using approved criteria.
• Maintains appropriate charting and reviews medical records for documentation completeness. Communicates with physicians to obtain orders for post-hospital care or additional documentation when screening criteria is not met for inpatient treatment.
• Collaborates with attending physician to define appropriate level of care and service that best meet the patients’ needs.
• Maintains appropriate documentation to include specific utilization review activities, maintaining confidentiality for patients and their families.
• Refers cases not meeting criteria to the Contracted Reviewer for determination of appropriate status.
• Communicates appropriate review information to HMO’s, PPO’s, and other third-party payers to certify patients for their hospital stay and services rendered.
• Monitors indicators such as length of stay, observation rates, delays in services, resource utilization, quality and satisfaction outcomes for individual stays and patient populations. Works collaboratively with patient health care team to identify opportunities for improvement and implement best practice solutions.
• Stays up to date on industry best practices and maintains a network of professionals to exchange ideas and benchmark best practices.
• Routinely assists other team members as needed. Works in various units or campuses in North Texas Medical Center to meet patient needs.
• This position performs other duties as assigned.

SPECIFIC DAILY RESPONSIBILITIES

• Review Medhost, census information and discharge reports.
• Update CM census report: remove discharges, add clinical information on current patients.
• Continuously update CM census report throughout the day as information is gathered during patient visits and interdisciplinary rounding, related to discharge location, plan of care, family requests, patient requests, transportation, etc.
• Conduct daily meeting with CCO and Directors, providing printed CM census report to all.
• Conduct Case Review meeting with HIM and Finance, reviewing admission criteria, change status, new orders for appeals, Peer to peers and ICD codes that need to be adjusted. Update throughout each day as needed.
• Facilitate and troubleshoot questions for the Hospitalist Physician as needed daily.
• Fax updated clinicals via Actifax to community partners listed in the discharge location. (ie; SNF’s, Home health, Hospice, ALF’s)
• Ensure that HIM is provided with: discharged patient CM assessments, chart documents, IMM’s, Choice letters, Oxygen orders, and Wound Vac orders.
• File other CM patient records, shredding quarterly.
• Provide missing diagnosis codes to PFS via spreadsheet entry.
• Conduct discharging-patient visits. Ensure patients sign the IMM form between 48 hours and 4 hours of discharge, and assist in overcoming identified discharge barriers.
• Conduct new-patient visits. Assess patients, explain discharge options and provide choice lists for SNF/HH/Hospice and have patients sign forms. Document assessment in Medhost.
• For inpatients, obtain order signatures and order Oxygen, wound Vacs, and IV abx for outpatients or those with home health.
• Conduct interdisciplinary rounds, leading the group rounding.
• Schedule, facilitate and communicate transportation plans for discharging patients (ambulance, air ambulance, private vehicle.)
• Send PASRR or MOT to receiving facility.
• Update the following spreadsheets as needed: Referral list, Policies, Readmissions, Appeals & denials, Delay in services, APS/CPS, UR committee reviews, MOON, IMM
• Meet with House Supervisor periodically, both in person and via Chat, to confirm clear communication on patient admits and discharges.

KNOWLEDGE AND SKILLS REQUIRED

• Computer skills including navigation of the internet and basic skills in Excel and Word.
• Excellent patient assessment skills including ability to analyze patient information, identify barriers to care, and develop creative and effective solutions is vital for managing complex cases.
• Strong organizational skills to prioritize tasks and manage schedules efficiently.
• Ability to work effectively with a multidisciplinary team, including doctors, nurses, and other service providers and community partners.

EDUCATION AND WORK EXPERIENCE REQUIRED

• Current Registered Nurse in the State of Texas – required
• BLS certification - required
• 2-3 years clinical nursing experience – required.
• BSN – preferred.
• 2 to 5 years position related experience – preferred.
• ACM or CCM certification – preferred.
• Knowledge of insurance guidelines, CMS requirements, and other payer requirements - preferred
• Utilization management certification – preferred.

LANGUAGE SKILLS

• Ability to communicate effectively in English both verbally and in writing
• Additional languages a plus

PHYSICAL REQUIREMENTS

• Ability to lift 25 lbs alone and 150 lbs with assistance
• Ability to stand for long periods of time
• Must be able to sit, stoop, bend and reach above head.