Under the direction of the Manager, Clinical Resource Management; the Case Manager is responsible for the activities of utilization management, case coordination and the development and implementation of a discharge plan for an assigned group of patients. The Case Manager serves as a resource for other members of the healthcare team and provides education to team members on issues related to the continuum of care, reimbursement, regulatory agency guidelines and resource use. Through collaboration, the Case Manager assures that the treatment plan is implemented accurately, in a cost effective and efficient manner in order to promote customer satisfaction and prevent delays in care and discharge.
Responsible for reviewing severity of illness and intensity of service indicators to assure that appropriateness of care criteria is met. Documents reviews and discharge planning in the medical record and/or the computer system as appropriate; Collects and maintains data for tracking and reporting for outcome studies and performance improvement.
Performs pre-admission, admission, observation, concurrent and retrospective reviews to evaluate the medical necessity of hospital services during the patient's stay. Assesses plans and implements a discharge plan appropriate to the patient's identified needs.
Coordinates the referral of cases to the Physician Advisor (PA) if not meeting approved criteria for admission or continued stay and distributes the "Important Message from Medicare" and Hospital Issued Notice of Non-coverage (HINN) when indicated. Ensures that all reviews are performed promptly. Facilitates optimum patient outcome and performance improvement.
Performs quality assurance screening and referrals as directed. Assist with rebuttal, appeal and external audit processes as assigned by the Manager or Director. Facilitates collaboration with other healthcare providers through the development of tools/processes to improve the coordination process.
Demonstrates responsibility for own competency/mandatories and annual performance evaluation by maintaining personal performance and competency assessment data up to date, attending all required programs and obtaining all professionally required CEU units. Prepares for annual evaluation conference through submission of completed skills lists, education attendance documents and self-evaluation form to the director during the month prior to the evaluation date. Maintains stable performance under pressure or opposition (such as time pressure); handles stress in a manner that is acceptable to others in the organization.
Registered Nurse, Bachelor's Degree in Nursing. 3 years of clinical experience. 1 year minimum experience in case manager role. Current license, etc. required by the profession.
Case Management Certification preferred, but not required. Computer skills, effective communication skills (verbal and written), time management and critical thinking skills. Working knowledge of healthcare reimbursement, counseling, community resources, continuum of care and team building.
Training in patient assessment home care planning and criteria review. Ability to communicate verbally and in writing.
Jackson Hosptial & Clinic