Req Number 001QDV
Job Category Case Management
Serves as liaison between the patient and facility/physician. Ensures a continuum of quality patient care throughout hospitalization and oversees provisions for patient's discharge. Assesses, plans, oversees and evaluates the appropriateness of care throughout admission and hospitalization of the patient.
· Participates in patient management rounds and patient centered meetings.
· Identifies potential delays and resolves issues with appropriate departments.
· Identifies appropriate utilization of Social Work Services and makes referrals when appropriate.
· Confers with physician regarding referrals for Physical Therapy, nutrition, speech and swallow.
· Serves as a resource to the health care team regarding quality, utilization of clinical resources, payer, and reimbursement issues.
· Works with on-site screeners in transitioning patients to appropriate post discharge settings.
· Collaborates with payers, providing all necessary clinical documentation for the maximization of benefits.
· Serves as a liaison to patient, family, admitting, primary care physician, health care team, and hospital departments.
· Collaborates with and provides feedback to the primary care physician and multidisciplinary team regarding patient’s status with regard to length of stay, utilization of resources and discharge status.
· Involves patient and/or family in discussion and planning for anticipated need for care following discharge.
· Ensures patient and/or family are given information regarding their choices regarding transferring the patient to another level of care according to regulatory standards.
· Conducts chart review for appropriateness of admission and continued length of stay.
· Contacts and interacts with third party payers to obtain approval of hospital days, pre-certification and post-discharge eligibility in relation to clinical course.
· Ensures compliance with current state, federal, and third party payer regulations.
· Identifies patients for Alternate Level Care (ALC) care list and notifies appropriate health team members.
· Communicates with insurance companies and physicians regarding utilization issues.
· Utilizes important message from Medicare (IMM) when appropriate.
· Ensures managed care reviews are up to date and accurately reflect patient’s clinical progress and acute needs.
· Submits data to management regarding case management and/or quality initiatives.
· Participates in data collection regarding patient’s length of stay, utilization of clinical resources, IPRO citations including appropriate recommendations and re-admission within 30 days.
· Reviews patient's chart.
· Assesses each patient physically, psychosocially and financially.
· Assesses patient's support system to facilitate appropriate discharge to community.
· Substantiates, with the physician, the need for home care services.
· Coordinates procurement of any supplies, equipment or home lab work needed by patient to evaluate discharge.
· Arranges for post-hospital transportation, when indicated.
· Interacts and coordinates with community agencies, families, vendors facilities and institutions to facilitate patient discharge.
· Completes and documents a psychosocial assessment on the patient.
· Documents on-going processes of patients’ hospitalization.
· Documents finalized discharge plan and disposition.
· Completes applicable areas of the Patients Discharge Instruction Sheet and the Patient Transfer Sheet.
· Ensures Patient Review Instrument ( PRI) is completed and reflects clinical profile of the patient.
· Ensures case management sheet is current and accurate.
*ADA Essential Functions
· Bachelor’s Degree in Nursing, required.
· Current license to practice as a Registered Professional Nurse in New York State.
· Case Management Certification, preferred.
· Minimum of one (1) year related experience, required. Experience in case management and clinical pathways, variance analysis and trending, quality management/utilization review and home care/discharge planning, preferred.
· Keeps abreast of developments in the field and serves as a resource to other staff.