JOB SUMMARY: The care manager coordinates the care and service of selected patient populations across the continuum.
He/she works collaboratively with physicians and other members of the health care team to achieve the highest quality clinical outcomes with the most cost effective use of available resources. The care manager assumes responsibility for an interdisciplinary process which assesses plans, implements, monitors and measures the effectiveness of interventions to meet patients' treatment and transitional needs. The care manager provides services to neonate, pediatric, adolescent, adult and geriatric patients and demonstrates the knowledge and skills necessary to offer care appropriate to the age of the patient.
I. Care Management Plan
A. Actively supports care management plans and process to measure, assess and improve quality, patient outcomes and care management metrics.
a. Collects data on variances from quality screening criteria approved by the appropriate committees, as needed.
b. Reports to Care Management leadership, identification of avoidable days and other Care Management measures including but not limited to, readmission, saved days, core measure monitoring, interventions, and delays, to ensure data is accurately collected.
c. Implements strategies in collaboration with the healthcare team to reduce length of stay (LOS) and resource utilization, never compromising quality or outcomes.
d. Participates in quality improvement activities using information and creative thinking skills to promote positive health status and improved outcomes; resolve problems; establish benchmarks as needed; identify and adopt best practices.
e. Implements action plans of identified improvements to resolve problems, increase effectiveness and efficiency, maximize resources and/or decrease cost and LOS as evidenced by dashboards.
f. Participate in performance improvement plans to improve patient satisfaction.
II. Acute Care Management
A. Provides the professional clinical component of the Acute Care Management model to ensure that department services support quality patient care and safety while coordinating patient throughput.
a. Prioritizes patient needs for Care Management services based on: target/high volume Diagnosis-Related Group (DRG), high cost, outlier, LOS, frequent inpatient admission, unplanned readmission or significant variance.
b. Supports the healthcare team with identifying decisions maker to ensure all plans and expectations are communicated in a timely manner including discharge plans and expected LOS outcomes and documents appropriately in the patient's electronic health record.
c. Identifies risk factors for potential crisis intervention needs related to clinical diagnosis, prognosis and/or patient/family dynamics.
d. Coordinates the discharge planning process.
Acts as a resource for discharge planning. Collaborates with the healthcare team to develop a discharge plan that includes the next step in the continuum (Post-acute services including Home Care, Durable Medical Equipment, Nursing Home Placement and/or other services) to identify patient needs relating to medical diagnosis, treatment, financial resources and psychosocial needs, assisting in transitioning patients to the appropriate Level of Care (LOC).
e. Ensures the multidisciplinary discharge plan is consistent with the patient's clinical course, continuing care needs and covered services.
Evaluates on an ongoing basis the patient's status and progress toward reaching goals set forth in the plan of care. Revises and updates treatment plans as necessary and provides supportive documentation.
f. Documents assessments, discharge plans and changes to discharge plans in the patient's electronic health record.
g. Participates in Touch Base Rounds in assigned areas and physician rounding on select patients.
h. Works collaboratively with healthcare team on appropriate documentation to accurately reflect the severity of patient's illness. Actively participates in the education of physicians and other healthcare team members on appropriate utilization of services and Level of Care (LOC) indicated by the clinical and/or socio economic situation to achieve optimal reimbursement.
i. Conducts referrals to Care Management Leadership, Vice President of Medical Affairs, Ethics Committee, Risk Manager, and Legal Services as appropriate.
j. Reviews daily admission and collaboratively creates a plan to positively impact desired outcomes.
III. Professional Clinical Component
A. Provides the professional clinical component of the inpatient Care Management model to ensure that department services support quality patient communication, education and financial components while coordinating patient throughput
a. Facilitates all issues surrounding patient care in a compassionate manner.
b. Supports the patient/family decision regarding advance directives or verifying a surrogate decision maker.
c. Works collaboratively to assess for clinical, spiritual, financial, educational, functional and psychosocial baselines for patient/family to determine appropriate and realistic outcomes.
d. Educates patient/family support system on the plan of care and expected outcomes. Improves patient/family understanding of and adjustment to the medical diagnosis/prognosis or other care issues.
e. Refers patient to community resources. Supports Heart Failure Process as assigned.
f. Ensures the negotiation for any benefit enhancements available to meet the discharge needs.
g. Assist with fiscal management by identifying cost containment strategies regardless of limitations of policy/benefits available to patient; uses supplies and equipment efficiently.
h. Issues patient notification for transfers of financial liability and counsels patients on utilization determinations when appropriate.
IV. Utilization Management
A. Ensures patients are in the appropriate Level of Care (LOC) according to evidenced based, physician approved criteria and standards and prescribed plan of care. Provides accurate documentation for financial follow through.
B. Obtains Discharge planning information from third party payer in a timely manner and per contractual agreements. Obtains authorizations in a timely manner for discharge planning needs.
C. Oversees the effective coordination of patient care services including: fiscal processing and assurance through managed care systems, initial evaluation and assessment, plan of care development, patient/family education and follow through with post discharge services and needs in a timely manner.
D. Performs reviews utilizing evidence based tool for reviews as necessary.
V. Denial Management
A. Maintains knowledge of managed care and government appeal processes and timelines.
B. Conducts through case reviews on all confirmed case denials including discussion with the appropriate Care Managers and Physician Advisors (PA)
VI. Transitional Planning
A. Works with interdisciplinary team to coordinate needed services to ensure efficient continuity of care.
B. Assesses need for services through collaboration with physicians and nursing staff;
C. Plans for care needs with active involvement of patient, significant others, hospital staff involved in treatment process;
D. Oversees implementation of transition plans with support from internal and external agents;
E. Monitors patients' progress and adequacy of planning process through regular communication with patients and service providers;
F. Documents actions in medical record according to departmental guidelines and oversees process of exchange of information with other facilities/agencies adhering to legal mandates about confidentiality;
G. Measures effectiveness of interventions through direct communication with patients and caregivers and data collection of defined indicators (e.g., overall length of stay, readmission rates, feedback from referral sources, etc.).
H. Identifies problems or gaps in community resources that impact outcomes and takes leadership role in efforts to effect changes.
A. Exhibits behavior and adopts practices to ensure optimal risk management and financial stability
a. Identifies potential risk management or clinical quality issues and resolves them through intervention or collaboration with other members of the healthcare team as appropriate or refers the issue to the appropriate individual(s).
b. Observes Universal Precautions consistently. Wears proper Personal Protective Equipment when appropriate.
c. Maintains knowledge of and adheres to current CHI-St. Vincent facility and Care Management Department policy and procedures.
B. Demonstrates ethical behaviors and provides confidentiality in all Care Management interactions.
a. Identifies and reports ethical situations to Care Management Leadership and Ethics Committee for resolution.
b. Respects patients/guest/coworkers personal property.
c. Maintains confidentially regarding personnel and strategic plans.
d. Maintain confidential Care Management interaction with vendors, third party payers and patient/family at all times.
e. Adheres to CHI-St. Vincent HIPPA policy and procedures.
VIII. Advocacy for Quality Outcomes
A. Acts as a patient advocate for optimum care and a business partner to the physician.
B. Participates as a team member to facilitate communication among all disciplines, identify barriers to meeting treatment goals, and determine ways to achieve best outcomes;
C. Provides information and support to patients and families, helping them access needed resources within the medical center and community;
D. Assists physicians in obtaining needed services for their patients and having access to all available data on best practice and financial outcomes;
E. Cultivates collegial partnerships with physicians and other health care professionals and maintains high customer satisfaction ratings in dealing with patients and their significant others;
F. Demonstrates innovative problem-solving skills and ability to analyze and organize data to provide evidence for necessary process changes
IX. Communicates Effectively
A. Resolves situations as appropriate within scope of job. Handles complaints/concerns in a prompt and courteous manner; assess and directs to appropriate person to deal with concerns as needed; makes attempt to solve issues with involved parties.
B. Demonstrates tact, courtesy, sound judgment and a professional attitude when relating with patients, families, coworkers, physicians, and affiliated agencies.
C. Gives and receives feedback in a positive manner.
D. Communicates both verbally and in writing with physician and appropriate hospital staff regarding patient needs and progress of discharge plan.
E. Meets with Care Management Leadership to discuss case specific issues.
F. Actively participates in staff meetings, for information exchange, discussion of performance indicator results and action planning.
G. Develops professional relationship with community partners.
X. Care Management Education
A. Provides Care Management education to peers and consumers; participates in providing continuing educational activities.
a. Assist with providing education of Care Management services, policies and procedures to physicians.
b. Actively seeks to improve skills and knowledge base for personal and job development through literature review and participation in in-services and other educational programs.
c. Consistently works toward standards of excellence to continually improve personal performance.
d. Responsible for ensuring current licensure, Basic Life Support (BLS) certification, and other required certification as applicable.
e. Responsible for documenting continuing education and mandatory in-service attendance and forwarding the information Care Management Leadership.
XI. Professional Public Image
A. Portrays a positive public image at all times.
a. Acts as a role model for others.
b. Recognizes, appreciates, accepts and values differences in people and treats all with dignity and respect.
c. Attends and participates in CHI- St. Vincent facility committees as assigned.
d. Wears clothing and CHI-St. Vincent identification badge consistent with dress code and attends to personal hygiene to maintain a clean, well groomed appearance.
e. Maintains attractive, safe, and clean workspace.
f. Meets CHI- St. Vincent facility attendance standards.
XII. Team Work
A. Builds and maintains positive relationships with healthcare team, placing organizational/team goals first.
B. Assumes responsibility, authority, and accountability for patient load, assisting other coworkers when requested or as the need arises.
C. Meets deadlines and takes responsibility for accomplishing one's own work.
D. Takes feedback from coworkers and uses feedback to improve performance.
E. Participates in peer evaluations.
F. Identifies and actively participates in projects to assist with team self actualization.
G. Participates as a team member with department wide events/programs.
H. Uses appropriate resources and methods to resolve conflicts with others in a positive and professional manner.
A. Documents data accurately in the utilization management module to ensure data for tracking and trending is accurate.
B. Uses technology for risk management, quality improvement activities, data collection, process improvement and evaluation of improvement interventions.
C. Maintains technical knowledge and skills of computer systems (Interqual, Cerner, Star, and Email)
XIV. Organizational Skills
A. Consistently makes appropriate mandatory reports to appropriate agencies.
XV. Performs other duties as assigned
Education: Registered Nurse with Bachelors degree or diploma/associates degree with care management certification within 2 years of hire date (CCM or ACM)
Licensure: A current unencumbered RN license to practice in the State of Arkansas is required.
Preferred: Masters degree & case management certification (CCM or ACM)
Experience: Requires Minimum of three years in acute care hospital
Preferred experience in case management, discharge planning or utilization management role
Recommended skills: Familiarity with case management role in health care setting
Knowledge of medical terminology, utilization management criteria, community resources, and health care reimbursement systems
Ability to analyze data, apply critical thinking process to problem-solving
Demonstrated capacity to work with inter- disciplinary team (especially physicians) and communicate effectively
Occasionally requires light physical effort as in periods of standing at files or
worktables, repeated changes of position within the work routine or prolonged sitting. Regular volume of work and deadlines impose strain on routine basis.
Nature of work requires substantive involvement in stressful situations causing strain. Frequent exposure to occupational hazards or contagious disease which requires routine precautions.
Catholic Health Initiatives