• Case Manager/RN

    ID
    2018-22125
    Department
    Case Management
    Work Hours
    0700-1530, 0800-1630, 1100-2330*, 1230-2100
    Position Type
    Per Diem
    Hours Per 2-Week Pay Period
    As Scheduled
    Location
    US-NY-Plattsburgh
    Weekend Requirements
    Weekends and holidays as scheduled
  • Overview

    The Case Manager monitors, collects and analyzes data and evaluates variances of resource utilization, complications and overall quality of care based on benchmarked criteria or established practices. The Case Manager in utilizing these skills assists the Medical Center in providing optimal care in a cost effective manner and promotes the efficient and effective use of patient services. The Case Manager’s role in data collection, analysis and summarization supports the Medical Center’s performance improvement/quality program, risk management, clinical pathway development and outcome measurement using guidelines from third party payors and external agency review processes.

     

    The Case Manager utilizes his/her skills to coordinate internal and external resources to facilitate appropriate resource management of an age specific patient population which spans from newborns to geriatrics, identifying opportunities for process improvement, high risk cases and sentinel events, to the achievement of an acceptable outcome.

    Special Criteria Details

    Minimum 2 weekend days and 4 days in a 28 day cycle. *WAIVER REQUIRED

    Responsibilities

    1. Demonstrates knowledge of Case Management services for age specific as related to discharge planning, admission criteria, and appropriate communication methods.
    2. Demonstrates knowledge of cultural diversity and can apply services respectfully.
    3. Demonstrates knowledge of hospital systems for efficacious care.
       a. Calls to expedite tests and procedures.
       b. Coordinates family meetings with physicians and care providers.
       c. Coordinates physician consultation and collaboration.
       d. Assists with bed management issues during high census periods.
       e. Facilitates discharges.
    4. Demonstrates time management skills by organizing effective daily schedule of tasks.
       a. Establishes daily and weekly plan for managing assignment.
       b. Establishes daily work list for insurance reviews.
       c. Prioritizes tasks effectively.
    5. Demonstrates knowledge of criteria for admission and continued stay.
       a. Demonstrates knowledge of InterQual and/or Milliman criteria.
       b. Applies admission and continued stay criteria appropriately.
       c. Applies discharge screens appropriately.
       d. Demonstrates knowledge of observation status.
       e. Provides complete and timely reviews to insurance companies.
    6. Demonstrates knowledge in assessment of patients and assignment to levels of care.
       a. Lowers level of care appropriately.
       b. Issues Medicare denials for admission and continued stay.
       c. Utilizes Physician Advisors appropriately.
    7. Demonstrates knowledge of denial process.
       a. Issues HINN letters correctly and follows IPRO process.
       b. Issues IM notices as appropriate.
       c. Communicates repercussions of denials to patient/family.
       d. Communicates process with physician(s).
    8. Demonstrates knowledge of appeal process.
       a. Can create an appeal letter.
       b. Communicates process with physician.
    9. Demonstrates ability to assess patients for continuing care needs.
       a. Assesses adequacy of home environment, social supports, and services available as reported by patient    and/or family.
       b. Develops appropriate care plan for patient with patient/family and the health care team.
       c. Re-assesses for needs as condition changes.
    10. Demonstrates ability to do effective discharge Planning Completes timely and correct PRIs.
       a. Provides patients and families with lists of choice for services (e.g. nursing facility).
       b. Demonstrates understanding of the types of care various facilities can provide.
       c. Assesses and refers patients appropriately for continuing care in Adult Homes, Sub Acutes, Nursing
    11. Facilities, Acute Rehab, etc.
       d. Assesses and refers for Hospice as appropriate.
       e. Refers appropriately for public health nurse follow up in the community.
       f. Coordinates durable medical equipment and anticipates other services as needed.
       g. Obtains necessary insurance authorizations for discharge needs.
       h. Informs patient and family of anticipated services and associated costs.
    12. Demonstrates good communication skills.
       a. Collaborates with fellow case managers sharing information about transferred patients, discharge planning expertise, and opinions on criteria.
       b. Participates in daily Interdisciplinary Rounds and collaborates with the nurses on the unit to develop care plans as well as PT, OT, ST, Dietary, Pharmacy, etc.
       c. Communicates with physicians to insure appropriate hospital utilization, care planning for the patient,   documentation and reimbursement.
       d. Keeps patients and families informed of care plan and plans for discharge.
    13. Demonstrates awareness of Core Measures, Patient Safety, and Quality Indicators.
       a. Insures completion of CHF discharge instructions.
       b. Refers to Quality Coordinators appropriately.
       c. Identifies and tracks readmissions.
    14. Demonstrates awareness of the financial implications of Clinical documentation and coding.
       a. Uses Physician Documentation Tool.
    15. Demonstrates awareness of regulatory Requirements.
       a. The Joint Commission – can express key requirements (e.g. plan of care).
       b. DOH – can express key requirements (e.g. high risk screening).
       c. CMS – can express key requirements (e.g. patient choice).
       d. HIPPA – can express key requirements (e.g. privacy).
       e. EMTALA – can express key requirements (e.g. provide emergency care).
       f. Demonstrates awareness of infection control practices.
       g. Screens for Child Abuse and Neglect.
       h. Screens for Elder Abuse.
       i. Screens for Domestic Violence.
    16. Documents timely and completely in the electronic medical records.
       a. Plan of Care.
       b. Discharge Needs.
       c. Insurance Reviews.
    17. Other duties as assigned.

    Qualifications

    1. Current New York State R.N. license required.
    2. CCM Preferred.
    3. Utilization review and discharge planning experience preferred.
    4. Three years of broad clinical nursing experience is required.
    5. Quality assurance/risk management experience preferred.
    6. Experience with interqual preferred.
    7. A high level of interpersonal skills and professional poise to interact with Medical Staff, other department staff, and Medical Center management is required.
    8. Knowledge of the prospective payment system and current insurers payment methodologies, coding and sequencing, and data collection and analysis is preferred.
    9. Assessment and goal setting skills, project management skills, and problem solving skills are required.
    10. Knowledge of Medicare, Department of Health, and The Joint Commission regulations is preferred.
    11. Knowledgeable in managed care processes is preferred.
    12. Computer experience preferred.
    13. Good written and verbal communication skills.
    14. As applicable, the individual has training/competency in attending to the special needs and/or behaviors appropriate to the age of the patients for which care is being provided.

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