Req Number 001GN8
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.
• 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.