Utilizing a collaborative process, the Access care manager will assess, plan, implement, monitor, and evaluate the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes. The care manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the patient and the reimbursement source.
RN's assigned to the Access position will provide care management intervention on behalf of individuals who are scheduled for surgical procedures. In collaboration with the care team, the Access care manager ensures the patients progress through the system in an efficient and cost effective manner. The Access CM remains involved in the patients care from scheduling of surgery, admission and during the evaluation phase of discharge planning will make recommendations for the discharge plan based on the assessment.. The Access CM serves as a resource for utilization management, i.e., level of care and assignment of appropriate status before admission, in the PPC and the post-surgical areas.
The care manager is accountable for a designated Access caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include:
Assessment - The care manager will collect in-depth information about a person's situation and functioning to identify individual needs in order to develop a comprehensive care management plan that will address those needs.
Planning The care manager will determine specific objectives, goals, and actions as identified through the assessment process. The plan should be action oriented and time specific.
Implementation The care manager will execute specific intervention that will lead to accomplishing the goals established in the care management plan.
Coordination The care manager will organize, integrate, and modify the resources necessary to accomplish the goals established in the care management plan. Monitoring The care manager will gather sufficient information from all relevant sources in order to determine the effectiveness of the care management plan.
Evaluation At appropriate and repeated intervals, the care manager will determine the plan's effectiveness in reaching desired outcomes and goals. This process might lead to a modification or change in the care management plan in its entirety or in any of its component parts.
Reviews all same day admissions before the scheduled day of surgery to ensure that authorization has been appropriately obtained and is in compliance with Medicare or other payer requirements standards of care. Identifies discharge needs apparent at time of scheduling and communicates them to the inpatient Case Manager as needed.
Screens and evaluates pre surgical patients for Care Management intervention. Initiates discussions with the attending physician for patients who do not meet appropriateness criteria and for whom alternative care arrangements can be made. Provides resources an ad education to the pre-surgical care team regarding utilization and care management.
Intervenes with the payer when needed to assist admitting personnel in obtaining authorization. Documents clinical information necessary to obtain approval from the payer as indicated in the patient medical record. Determines medical necessity and appropriateness of admission and stay in accordance with InterQual screening and utilization of the inpatient only list from Medicare.
Determines medical necessity and appropriateness of admission and stay in accordance with InterQual screening for observation patients.
Identifies appropriate processes to manage and charge for observation services.
Works with Patient Access and Pre Cert department to understand the pre-certification requirements of all contracted payers. As an advocate assures authorizations for services are obtained before provided as appropriate.
Assesses all scheduled procedures and tests for appropriate medical necessity. Assists in preparation of Medicare/Medicaid hospital ABNs when patient's outpatient care is not covered according to the guidelines. Validates admission criteria with third party payers (including onsite and telephonic Case Managers) as well as Primary Care and Attending Physicians.
Recommends alternative care sites where appropriate. Coordinates/facilitates patient care progression throughout the continuum. Works collaboratively and maintains active communication with physicians, nursing, and other members of the multidisciplinary care team to effect timely, appropriate patient management.
Collaborates with the denials manager and helps to respond to all pre-certification denials while identifying the issues and providing a proactive appropriate to pre-certification denials management.
Collaborates with medical staff and nursing personnel to assure accuracy and completeness of patient status orders, assuring variances from admission standards are identified during the patient admission. Maintains a computer database, including input of new data elements and correction and updates of existing elements.
Prepares performance improvement reports as needed. Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Provides clinical review, including clinical reviews, to payers in accordance with established standards, procedures and policies.
Documents authorization and days approved data as outlined in the departmental policy and procedure. Refers patients to Access personnel once appropriateness of setting and care requirements are met to obtain preauthorization/pre-certification. Reviews requests for transfers from other facilities to ensure that the patient's condition necessitates the transfer and provides feedback to the sending facilities regarding determination.
As clinically appropriate arranges for the patient's return to the transferring facility. On a daily basis, assesses the actual and potential available beds, scheduled admissions and urgent patients awaiting admission. Communicates potential issues in care needs, reimbursement and/or discharge planning related to individual patients to the appropriate Case Manager and/or Social Worker and documents same in the patient's medical record.
Initiates letters of non-coverage for Medicare patients not meeting preadmission/ admission criteria or for services not covered by Medicare. Analyzes issues and trends in bed management and utilization of resources and strategizes to address them and follow through on proposed solutions. Actively participates in clinical performance improvement activities.
Assists in the collection and reporting of financial indicators including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials, and appeals.
Uses data to drive decisions and plan/implement performance improvement strategies related to care management for assigned patients, including fiscal, clinical, and patient satisfaction data.
Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provider.
Collects, analyzes, and addresses variances from the plan of care with physician and/or other members of the health care team. Uses concurrent variance data to drive practice changes and positively impact outcomes.
Collects delay and other data for specific performance and/or outcome indicators.
Assists in the collection of data regarding LOS, resource utilization, denied days, costs, case mix index, patient satisfaction, and quality indicators (e.g., readmission rates, unplanned return to OR, etc.).
Report quantifiable impact, quality of care and/or quality of life improvement as measured against the care management goals.
Provide coverage for other unit-based Care Managers, as directed. Perform other duties as needed.
Adheres to all of BMC's RESPECT behavioral standards
Graduate of an accredited BS Program in Nursing
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
Licensed to practice as a Registered Nurse in the commonwealth of Massachusetts
CCM or related certification attained within 24 months from the hire date is preferred
3-5 years of diversified clinical experience is required
A minimum of 2 years of previous experience involving judgment and decision making, preferably in a utilization management/case management position
Coordination and Service Delivery The care manager will understand confidentiality and the legal and ethical issues pertaining to it; understand medical terminology, how to obtain an accurate history; establish treatment goals; establish working relationships with referral sources; develop treatment plans.
Physical and Psychological Factors The care manager will understand methods for assessing an individual's level of physical/mental impairment; understand the physical and psychological characteristics of illness; be able to assist individuals with the development of short- and long-term health goals.
Benefit Systems and Cost Benefit Analysis The care manager will understand the requirements for prior approval by payer; be able to evaluate the quality of necessary medical services; be able to acquire and analyze the cost of care; understand the various health care delivery systems and payer plan contracts; be able to demonstrate cost savings.
Case Management Concepts The care manager will understand case management philosophy and principles; apply problem solving techniques to the care management process; document care management services; understand liability issues for care management activities.
Community Resources The care manager will understand how to access and evaluate the available resources to meet a client's needs; will be able to develop new resources.
KNOWLEDGE AND SKILLS:
Extensive background and knowledge of current medical/surgical patterns of practice.
Medical terminology and standard medical abbreviations.
Managed care concepts, the various health care delivery systems
Methods for assessing an individual are level of physical/mental impairment, understanding of the physical and psychological characteristics of illness, and understanding of expected treatment.
Confidentiality issues and the legal and ethical issues pertaining to them.
ICD-9 and CPT nomenclature and the ability to interpret and convert this information, as applicable.
Knowledge of benefits and various plan contracts, eligibility issues and requirements.
Role and functional responsibilities of case management professional; case management program philosophy and purpose within Managed Care Program
Excellent interpersonal, verbal and written communication and negotiations skills
Strong analytical, data management and PC skills
Boston Medical Center