The Case Manager coordinates, negotiates, procures services
resources for and manages the care of complex patients to
facilitate achievement of quality and cost, patient outcomes. The
Case Manager works collaboratively with interdisciplinary staff
internal and external to the organization. The Case Manager
participates in quality improvement and evaluation processes
related to the management of patient care. The Case Manager will
review all patients for utilization management and appropriate
discharge planning. The Case Manager's average caseload will be
1:15-25. The Case Manager that is BSN prepared will be a leader in
the Case Management practice. The Case Manager will work
cooperatively with the Physician Advisor and Team.
DUTIES AND RESPONSIBILITIES:
Determines medical necessity and appropriateness of admission
and stay in accordance with Interqual.
Prepares Medicare/Non Medicare hospital notices of noncoverage
(HINN) when patient's level of care is no longer covered according
to the guidelines.
Identifies the appropriate patients for Case Management
Maintains a working knowledge of the requirements of 3rd party
payers most frequently involved with their caseload population.
Maintains a working knowledge of the resources available in the
Communicates, collaborates, coordinates and negotiates with
physicians, other members of the team, the patients payers and
administrators to assess the needs and provide a plan of care for
their caseload population.
In conjunction with the patient/family, other members of the
health care team, the payer, and available resources, formulates a
plan to address assessed needs and issues, implements the plan,
evaluates the effectiveness of the plan in meeting established care
goals and revises the plan as needed to reflect the changing needs,
issues and goal.
Evaluates the effects of Case Management on target
Explores and facilitates strategies to reduce length of stay and
resource consumption within case managed populations, implements
these strategies and documents the results.
Manages each patient's transitions through the Health Care
Maintains appropriate documentation of the patient care and
Identifies the need, arranges for and conducts health care team
meetings when necessary to facilitate the coordination of services
and resources in complex situations.
Educates, health team colleagues about case management,
including the role and the unique needs of case managed patient
- As a member of the Case Management practice:
a. Seeks and provides peer consultation about cases presenting
problems and/or experiencing significant deviation from the plan of
b. Consistently attends daily care rounds and participates in
c. Facilitates and participates in programs of care meetings
related to the appropriate case managed population.
d. Manages the appropriate collaborative care plans related to
case managed population including and monitoring appropriate
e. Arranges for and participates in coverage during long, short,
and unexpected absence of self and other case managers.
f. The Case Manager tracks and trends LOS, resource utilization,
outliers, readmissions, denials, delay days and satisfaction of the
case managed population.
g. Consistently attends case management staff development
h. Maintains a close working relationship with physicians
managing the care of their caseload population.
i. Is a resource person for the education of the case management
j. Identifies areas of knowledge deficit in our system and takes
measures to reduce that deficit.
Coordinates patient discharge and transfers based on the
patients need and available resources.
Coordinates services, i.e. home help, DME etc, based on patient
need and resources available.
Acts as a resource to the team regarding insurance benefits,
managed care processes, and utilization issues.
Is responsible for attending all annual mandatory educational
programs as required by position.
Employee understands and demonstrates the importance of
satisfying the needs of the customer/patient by interacting with
him/her in a friendly and caring way, being attentive to the
customer's needs, both psychologically and physically, and by
taking the initiative to maintain communication with the customer
in order to provide a secure and pleasant experience with the
- It is understood that this job description lists typical duties
for the classification and is not to be considered inclusive of all
duties that may be assigned.
Case management staff meeting. Case management staff development
meetings. Programs of care.
Graduate of an approved registered nursing program with a
current license as a registered nurse. BSN or Case Management
Three years clinical nursing in acute care hospital setting or
two years utilization management in an acute care hospital setting.
Case management experience preferred but not required.
CARDIOPULMONARY RESUSCITATION (CPR) REQUIREMENTS:
Basic Life Support (BLS) required within 90 days of hire
Light physical effort. Routine office job.
Category I. Tasks that involve exposure to blood, body fluids,
A.D.A. Essential Functions