The Case Manager 1 directs the utilization review of patient charts, treatment plans, and discharge planning pertaining to the quality of care and treatment criteria for patients in a specific department. The Case Manager 1 specializes in the review of information pertaining specifically to the assigned areas. Relies on education, experience, professional training and judgment to accomplish responsibilities. A wide degree of creativity and latitude is expected. Works under minimal supervision.
Most, but not all, of the accountabilities below may apply to each specific area.
Evaluation and Analysis
- Contributes to cost effectiveness/efficiency and demonstrates awareness of benefit system and cost benefit analysis. Demonstrates the ability to maximize financial outcomes of assigned patient load using the continuum of care philosophy. Assists in the development, monitoring, and analysis of annual financial goals of targeted population.
- Understands the capabilities of outside referral sources such as home health, sub-acute care and skilled nursing facilities. Understands the different types of healthcare delivery systems and the requirements for prior approval by payor for admissions, procedures, and continued stay.
- Meets with treatment team to provide utilization review information, discusses issues pertaining to continued stay, discharge and aftercare plans, evaluates current financial resources, and discusses whether documentation reflects the need for continued stay and at what level of care is the most appropriate.
Partnership and Collaboration
- Performs effective utilization review techniques to work with physicians, third party payors, and federal and local agencies to prevent denials of payment or days.
- Acts as a resource for unit personnel in the resolution of utilization/case management problems and expediently communicates identified problems to appropriate personnel in an effort to enhance departmental operating efficiency.
- Collaborates with all members of the health team to ensure reimbursement optimization, appropriate discharge planning, and cost-effective quality care. Plays a key role in the discharge planning process assessing patient's needs for referrals and/or alternate levels of care. Appropriately tracks and reports avoidable days.
- Demonstrates competence in coordination and service delivery. Understands methods for assessing an individual's level of physical/mental impairment. Assesses patient clinical information and in collaboration with the healthcare team, develops treatment/discharge plans.
Quality
- Evaluates the quality of necessary medical services, utilizes criteria to determine medical necessity of admission and interacts with physicians to facilitate patient assignment to appropriate alternative of care.
- Provides appropriate and timely information to third party payors to facilitate financial outcomes and ensures patients are receiving appropriate level of care; includes coordinating denials/appeals.
- Demonstrates ability to access and utilize community resources. Is knowledgeable of the ADA and other federal legislation affecting individuals with disabilities. Knows how to establish a client support system.
- Observes and adheres to all departmental and hospital policies and procedures, and follows all safety, quality assurance, and infection control standards.
- Promotes the quality and efficiency of his/her own performance by remaining current with the latest trends in field of expertise through participation in job-relevant seminars and workshops, attendance at professional conferences, and affiliations with national and state professional organizations.
Other Duties as Assigned
- Performs other duties as assigned or requested.
Experience: Three years in general or specialty nursing practice
Education: Associate's Degree
Licensure: Current and unrestricted Louisiana State License as RN
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