We have an exciting opportunity to join our team as a Case Manager.
In this role, the successful candidate The Case Manager is responsible to coordinate and ensure that the interdisciplinary plan of care and the discharge plan are consistent with the patients clinical course, continuing care needs and covered services. The Case Manager encourages and facilitates a high level of collaboration and identifies and cultivates relationships with key stakeholders. The Case Manager utilizes an understanding of statistical & financial information to solve problems. The Case Manager participates in departmental and hospital wide process improvement activities.
Assesses patient needs in collaboration with the interdisciplinary team to develop a comprehensive management plan, documenting the assessment and plan in Allscripts, with printed/electronic copies to the medical record.
Conducts Performance Management monitoring and participates in problem identification and solutions to improve key processes/ systems/patient care
Participates in unit, departmental and hospital-based councils/activities/special projects.
Assimilates LMC core values Dignity, Respect, Inclusivity, Compassion throughout all processes and interactions.
Utilizes effective conflict-resolution strategies when dealing with staff, physicians and family members.
Responds to patient/family needs in timely, positive manner and ensures service excellence among all staff.
Assumes ownership/ accountability for process improvement efforts
Works effectively in uncertain situations
Assimilates complex information and concepts
Responds flexibly to shifting priorities and rapid change.
Obtains third party payer certification for patient status change, information needed for discharge.
Facilitates physician discussion with medical director of third party payer in an attempt to overturn potential denial.
Assists in the appeal process (concurrently and retrospectively) for appeal of days and procedures.
Documents clinical reviews in Allscripts, and forwards same to appropriate payer as necessary.
Communicates salient clinical parameters through chart abstraction
Facilitates clinical managed care reviews to avoid technical denials
Collaborates with the physicians and interdisciplinary care team regarding expected LOS for specific patients utilizing MCG criteria and Medicare benchmarks. Ensures that the team is actively working towards transition to the next level of care and identified expected discharge date.
Prevents length of stay delays by recognizing when the acute level of care is no longer necessary and continued ongoing testing/treatment can be rendered on an outpatient basis, working with the clinical staff to ensure that such services are scheduled and approval obtained to facilitate the appropriate discharge and follow up.
Facilitates efficient care processes and follows through on delays in work-up, treatment and/ or discharge. Expedites testing/procedures to prevent avoidable delays and facilitate movement towards next level of care.
Refers potentially avoidable days to physician advisor when appropriate
Discusses medical necessity, as identified by the use of clinical criteria, with the interdisciplinary team to facilitate timely movement to the next level of care
Assesses appropriateness of patient s admission, need for continued stay, level of inpatient care and discharge level of care
Acts as a resource to physicians/ staff regarding MCG criteria for top DRG s on CM s unit
Coordinates post discharge appointments with PCP to ensure cross continuum continuity of care.
Communicates promptly and effectively with responsible medical, nursing and ancillary staff to ensure documentation adequately reflects patient clinical status, admission status and need for continued stay.
Monitors patient progress toward goals
Provides informal education for hospital personnel that enhance their knowledge regarding clinical pathways, reimbursement issues, federal/state regulations, discharge planning issues and early recognition of post-hospital needs.
Encourages and facilitates high level of collaboration with medical staff, interdisciplinary team, and agencies contracted to provide continuing care services.
Demonstrates knowledge of disease process, available resources, and treatment modalities, assessing their quality and appropriateness for specific disabilities, illnesses and injuries.
Avoids potentially unnecessary days through the timely completion of the PRI and home care transfer documents. Documents avoidable days in the Allscripts system.
Identifies potentially unnecessary days and discusses plan of care with treatment team to reduce or eliminate same. Escalates problem as per process to eliminate delays as possible.
Prepares and updates PRI, using Allscripts, to reflect current changes in patient status.
Ensures post discharge plan of care is appropriately coordinated with and communicated to providers of post discharge care including but not limited to significant others, SNF and home care agencies
Demonstrates ability to implement an alternative plan for discharge when modifications are required.
Coordinates and ensures that the interdisciplinary plan of care and the discharge plan are consistent with the patient s clinical course, continuing care needs and covered services
Identifies barriers to care and discharge and presents information to appropriate operational leaders to assist in the development of strategies for improvement
Anticipates and/or identifies discharge planning issues and effectively collaborates with the social worker, patient accounts representative, home care and /or skilled nursing facility liaison, other outpatient care representatives to address needs such as financial aid and/or post-acute service arrangements.
Works to ensure that patient outcomes are achieved within established timeframes using appropriate resources.
Demonstrates an ability to identify and shift priorities within work assignment to effectively manage patient care load.
Collaborates daily with interdisciplinary team for assigned patients to discuss patient care planning and care facilitation
Discusses estimated length of stay, treatment and discharge plan with the attending physician and patient/family. Initiates discharge planning at the time of admission, and continues throughout the inpatient stay.
Performs other duties as assigned or volunteered in alignment with medical center mission, goals and values
Minimum Qualifications: To qualify you must have a Bachelors Degree required. Registered Nurse License-NYS Recent 5 years of Med/Surg experience with demonstrated leadership skills required Experience in Quality Improvement, Utilization Management, Case Management preferred. Case Management certification preferred. BLS required
Associated topics: business development, development, development manager, liaison, plan, program development, program management, project development, project management, resource development