This position is responsible and accountable for the management of care for an assigned patient population by unit, across the continuum of care. The Case Manager works to achieve daily clinical, quality and cost outcomes by providing well-coordinated experiences for patients/families through the synchronization of care activities of multiple disciplines and negotiating with third party payors.
This is accomplished by negotiating, procuring and coordinating services and resources needed by patient/family; ensuring and facilitating the achievement of quality and clinical customer service; cost and clinical outcomes; intervening at key points for individual patients; addressing and resolving patterns or issues that have a negative quality-cost impact; and creating opportunities and systems to enhance outcomes.
PRINCIPAL DUTIES AND ESSENTIAL FUNCTIONS:
CARE COORDINATION COMPLETES:
Case Managers complete assessments on all new admissions to determine the need for all appropriate Case Management services.
Conducts daily multidisciplinary rounds on assigned units, reviews patient’s plan of care and coordinates:Assessment of patient/family needs
Completion and report of diagnostic tools in a timely manner
Completion of treatment appropriate for the acute episode of illness
Modification of plan to meet continuing care needs of the patient
Monitors ongoing process of gathering adequate information from all relevant sources to insure operation of plan
Discusses estimated length of stay, treatment and discharge plan with the attending physician and healthcare teamEstablish strong, collaborative relationships with your physicians and team members
Discusses with MD the appropriateness of resource utilization, consults and treatment plan
Ensures that the interdisciplinary care plan and discharge plan are consistent with the patient’s clinical course, covered services and continuing care needs.
Identifies patients and families with complex psychosocial, financial and legal discharge planning needs and refers them to social work.
Incorporates knowledge of clinical expertise, quality initiatives, insurance and finance into decision-making and problem solving of individual patient cases and across case type during care management activities.
Fosters and maintains a positive working relationship with referral agencies and liaisons to enhance patient flow.
Collects and reports on quality projects, i.e.:CHF
Re-admissions within 30 days
Delay Day Variances
Documents patient/family progress towards discharge and all critical events and information associated with the hospital stay in SoftMed.
Supports the EMR and all computer programs, including SoftMed and Soarian.
Using Interqual criteria, reviews appropriateness of admission, the need for continued stay and information needed for discharge.
Responds to third party payor requests for concurrent clinical information in timely manner.
Ensures that documentation in the medical record supports the admission and continued stay, in order to reduce denial rate.
Documents care management activities in the initial assessment and as the patient progresses towards discharge and at discharge.
Inteacts with Admitting, Financial Counselors, Insurance Case Managers, Finance and Screeners as appropriate.
Maintains clinical competency and current knowledge of regulatory and payor requirements to perform job responsibilities.
Works with documentation specialist to have accurate length of stay information.
Provides superior customer services to all internal and external clients, customers and patients
Completes roles and functions related to discharge planning/coordination including case identification, high risk screening, assessment of patient and resources, goal setting, implementing, maintaining and evaluating process. Goal is to complete within 24 hours.
Coordinate all discharge activities.
Initiate all appropriate referrals to continuum of care agencies in a timely manner.
Facilitates patient transfer from one level of care to the next.
Incorporate the highest standard of professional, clinical, legal and ethical practice into their own daily practice (i.e. patient’s rights, maintains confidentiality, role model to nursing).