The Case Manager (CM) will be responsible for all aspects of case management for an assigned group of patients to determine the appropriateness of the Level of Care, assist in the development of the plan of care; ensure that the plan is implemented in a timely basis and identify the expected length of stay (ELOS). The CM works collaboratively with physicians, social workers, clinical nurses, home care services, and other members of the interdisciplinary team as needed. The CM actively participates in specific clinical initiatives focused on reducing the length of stay (LOS), improved efficiency, quality and resource utilization. Assignment will be by units/clinical areas of practice and may require responsibility on other units/services
1. Principle Duties and responsibilities include, but are not limited to:
a. Reviews all new admissions to identify patients where utilization review, discharge planning, and/or case management will be needed using standardized criteria to achieve optimal patient outcomes and appropriate reimbursement for the organization.
b. Performs continued stay reviews utilizing standardized criteria to justify continued inpatient stay.
c. Collaborates with Physician and other clinicians to expedite diagnostic testing, treatment and consultations.
d. Documents all clinical reviews in Case Management Documentation system.
e. Supports the mission, vision, philosophy and goals of the Medical Center.
2. Case Management: The CM process will include:
a. Assessment of the patients clinical, psychosocial, and functional status in collaboration with the interdisciplinary team.
b. Identification and documentation of variances affecting the LOS and the discharge planning process.
c. Conducts follow-up of any delays in treatment or reporting of results.
d. Planning/developing specific goals with the physician, interdisciplinary team, and the patient and/or family.
e. Implementation and coordination of specific activities, strategies, and interventions to move the patient through the continuum of care.
f. Documentation of outcomes achieved and identified internal and external barriers.
g. Identifies reasons for readmissions and collaborates with interdisciplinary team on strategies to reduce readmission rate.
h. Appropriately identifies and refers cases to the physician advisor to support timely progression of patients along the continuum of care and (appropriate) discharge planning.
i. Interacts with patient/family to discuss plan of care and coordination of services based on clinical needs and available resources.
3. Utilization Review:
a. Maintains a working knowledge of the UR (Utilization Review) requirements of each payor within the patient population;
b. Provides the clinical information requested by the managed care companies as part of the concurrent review in a timely fashion.
c. Provides clinical information requested by the managed care companies in accordance with contractual agreements.
d. Works collaboratively with physicians and managed care companies on concurrent denial appeals
e. Communicates clinical information to the payor, as needed, coordinating direct communication between physician and payor Medical Director as required.
f. In psychiatry, the CM will document UR notes in the medical record as per OMH guidelines.
4. Discharge Planning:
a. Responsible for assessment, communication and monitoring of discharge planning process (The clinical nurse initiates the discharge planning process on admission).
b. Obtains authorizations from managed care companies for post-discharge services.
c. Assesses for clinical readiness and completes the Hospital and Community Patient Review Instrument (PRI) for patients requiring Residential Health Care Facility placement.
d. Liaison with financial department for current insurance coverage.
5. Collaborates and participates in the appeals process with all members of the interdisciplinary team.
6. Collaborative Relationships:
a. Develops and maintains effective working relationships with interdisciplinary team and Case Managers within the managed care organizations.
7. Participates in nursing orientation.
8. Interfaces with other departments in the Medical Center.
Education Requirements
Bachelors Degree in Nursing; Masters preferred.
Experience Requirements
Previous experience as in homecare, long term care or utilization review preferred.
Discharge Planner or Case Manager preferred.
Manager or a minimum of 3-5 years experience as a RN in an acute care setting.
Licensing and Certification Requirements:
Current NYS RN nursing license.
CCM certification preferred. Re-credentialing of CCM status expected.
PRI Certification (to be obtained within 1 year)
Name: Basic Life Saver (BLS) Issuing Agency: AHA
Collective bargaining unit: NYSNA-MSH