Case Manager - RN

The Case Manager 1 directs the utilization review of patient charts, treatment plans, and discharge planning pertaining to the quality of care and treatment criteria for patients in a specific department.  The Case Manager 1 specializes in the review of information pertaining specifically to the assigned areas.   Relies on education, experience, professional training and judgment to accomplish responsibilities.  A wide degree of creativity and latitude is expected. Works under minimal supervision. 

      1.   Evaluation and Analysis: This will have been satisfactorily performed when…

• Admissions are reviewed for appropriateness using established Interqual criteria within 24 hours of admission/next working day has been performed as evidenced by no denials due to inappropriate status.
• Current treatment plans are reviewed daily to evaluate appropriateness of services and progress toward treatment goals as evidenced by direct observation in IDT by the Director and/or Manager and/or updates provided to LOS report.
• Appropriate referrals for assistance are identified, and for those patients having complex or high risk discharge needs, Social Services is consulted for further assistance.
• Care/services provided are monitored for potential opportunities for improvement or possible deviation from standards of care, protocols, and/or completion of core measure pathways as evidenced by direct observation in IDT by and by documentation.
• Staff/physician/payors and patients are notified of discharge plans and needed action to implement as evidenced by direct observation in IDT and documentation in the medical record.
• All activities required to facilitate a smooth and timely discharge from the acute care setting for assigned patients are initiated and completed within specified guidelines and timeframes at all times. Patient needs are identified and resources available to meet those needs utilized as evidenced by direct observation in IDT and documentation.
• Appropriate intervention strategies are determined and appropriate solutions/strategies utilized by applying clinical judgment/knowledge and/or critical thinking skills to problem solve as evidenced by direct observation in IDT by and documentation.

      2.   Partnership and Collaboration: This will have been satisfactorily performed when…

• All involved entities (including EHR) when admission fails to meet criteria for admission are notified, followed by immediate documentation of information as evidenced by documentation.
• Business Office is immediately notified when category changes occur evidenced by audits of roll over sheets.
• Payors are notified of admissions and discharges per protocol. Communication of accurate information with payor and physician to ensure coverage for services/care is provided. Immediate notification of physicians and Business Office if potential non-coverage issues evolve as evidenced by no denials of days or stay received.
• Unit-based Interdisciplinary Team meetings are facilitated, and effectively collaborate with others involved in discharge plans and improvement of identified unit/disease specific metrics (LOS, Core Measures, etc), as evidenced by direct observation in IDT
• Physicians are notified of need for additional documentation or adjustments to treatment plan to promote continuum of care. Suggestion are made to staff and physicians to optimize efficiency of services provided and minimize consumption of resources as evidenced by decreasing LOS and avoiding denials.
• Positive, competent and respectful interaction with patients, families, caregivers, staff, co-workers, physicians, and community agencies is given at all times as evidenced by no verbal or written complaints.

      3.   Quality: This will have been satisfactorily performed when…

• Tracking avoidable days and denials is submitted to the Director and/or Manager; Avoidable Data documentation is completed timely for peer review as evidenced by reports.
• Prompt notification of CM Manager or Director of possible quality issues as evidenced by direct observation in IDT by the Director and/or Manager.
• Confidentiality is maintained at all times when dealing with patients, staff or physician issues as evidenced by no written or verbal complaints.
• Appropriate priority is given to provide high quality care by ensuring guidelines are followed for core measures through concurrent chart review and follow-up with appropriate healthcare provider as evidenced by reporting in IDT and/or updating core measure spreadsheet.
• Concurrent appeals are conducted and notification to Director of CM is made for all denials to ensure prompt tracking as evidenced by reports that are submitted to the Director.
• Results of review, preparation of "Avoidable Day" sheets and notification of appropriate personnel has occurred. Physicians are notified of need for additional documentation or adjustments to treatment plan to promote continuum of care as evidenced by updates in IDT and/ or updates to daily LOS reports.

      4.   Other Duties as Assigned: This will have been satisfactorily performed when…

• Other duties as assigned are completed.
• Actively serves on committees as requested.

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