Job Description

Inspire health. Serve with compassion. Be the difference.

The Hospital Case Manager (HCM) provides case management service for hospital patients, including, but not limited to, utilization management to ensure efficient, cost-effective patient progression through the continuum of care and discharge to an appropriate level of care. In collaboration with physicians, leads the multidisciplinary team including clinical staff and payors to ensure efficient delivery of quality, cost-effective care.

Accountabilities

• Participates in discharge planning activities for patients with complex medical issues, in order to ensure a timely discharge and to provide appropriate linkage with post-acute care providers. Accountable for appropriate levels of care and length of stay focus - 10%
• Consults with interdisciplinary team, Physician Advisor and administrative leadership as necessary to resolve barriers regarding progression of care. Collaborates with physicians throughout hospitalization, develops an effective working relationship, and provides expertise regarding payor and regulatory guidelines. - 10%
• Addresses and resolves system problems impeding diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles during the hospital discharge planning process. Monitors the patient progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focuses, high quality, efficient, and cost effective. - 10%
• On the basis of preliminary risk screening, assesses patients’ and family’s psychosocial risk factors through evaluation of prior functioning levels, appropriateness and adequacy of support systems, reaction to illness and ability to cope. - 10%
• Advocates for patient and family empowerment and independence to make autonomous health care decisions and access needed services within the health care system. - 10%
• Maintains expert level knowledge of body systems and expected clinical outcomes for patient disease process. Maintains current knowledge of changes in state and federal regulatory requirements related to the provision of case management services in a tertiary acute care setting.Maintains case management knowledge to provide services in accordance with standards of practice as established by department and management. - 10%
• Uses established clinical guidelines for initial/admission and continued stay reviews for patients within assigned unit to ensure medical necessity, appropriate level of care and timely implementation of plan of care in accordance with hospital(s) Utilization Review Plan. - 10%

• Promotes effective and efficient utilization of clinical resources, ensuring quality, cost effective care.

  Provides timely clinical reviews to third party payors. Responds to requests for additional information within 24 hrs or next business day. - 10%
• Ensures that patient goals are set with patient/family, negotiates healthcare resources and educates patient/family regarding options of care throughout the continuum. Monitors patient's progress and intervenes as necessary to ensure delivery of quality, efficient, cost-effective services. - 10%
• Serves as a resource for patients and families with regard to their rights and responsibilites, when payment of care is denied or when care is no longer medically necessary. Includes, but not limited to, delivery of the regulatory documents as provided by CMS. - 10%

Minimum Qualifications

• Education - Bachelors degree in nursing
• Experience - Three (3) years acute care nursing experience. One (1) year acute case management experience preferred.

Required Licensure - South Carolina RN license

Other Required Skills/Experience

• N/A

Work Shift

Day (United States of America)

Location

Richland

Facility

1510 Richland Hospital

Department

15107517 Hospital Case Management

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