Responsible for the provision of case management services which primarily involves care transition, discharge planning, utilization management, and coordination of healthcare services across the continuum. Optimizes clinical and financial outcomes in the delivery of patient care.
Essential Functions / Major Responsibilities:
- Manages individual patients and at-risk patients across the health care continuum to achieve optimal clinical, financial, operational, and satisfaction outcomes.
- Assesses, coordinates, negotiates, procures and facilitates the utilization of resources for patients to achieve high quality and cost effective outcomes.
- Acts in a leadership function with the Interdisciplinary Team to collaboratively develop and manage the care transition patient discharge plan, and effectively communicates the plan across the continuum of care.
- Coordinates healthcare services across the continuum. Identifies issues that may delay patient discharge and facilitates resolution of these issues.
- Serves as a patient and family advocate; engages patients, family and caregiver to be active participants in their care and assists them in navigating the healthcare system.
- Assesses, plans, implements, coordinates, monitors and evaluates for appropriate disposition, collaborating with the healthcare team to formulate and achieve a cohesive, comprehensive discharge plan.
- Assists, and facilitates, in the identification, research, isolation and resolution of potential utilization/resource management problems.
- Evaluates the medical necessity and appropriateness of care utilizing standard criteria. Collects and communicates pertinent information to payors and others to meet utilization goals. Assists with recovering denials of payment.
- Conducts medical record reviews evaluating the utilization of facilities and services for appropriate levels of patient care.
- Performs and communicates the reviews to meet organizational and third party payor requirements.
- Aggregates, displays and conducts first level analysis of data.
- Assists in assurance of optimal reimbursement from third party payors by providing concurrent and retrospective reviews of admissions, readmissions, observations and transfers.
- Advocates for the patients and family with third party payors and service providers.
- Facilitates and participates in process improvement activities for populations of patients to achieve optimal clinical, financial, operational, and satisfaction outcomes.
- Utilizes current evidence-based knowledge, protocols and criteria for data based decision-making skills and facilitates utilization of regulatory guidelines that promote appropriately controlled resource utilization.
- Actively participates in the appeal process and issuance of denial letters with physician assistance.
- Establishes and promotes collaborative relationships with physicians, payers, and other members of the health care team.
- Educates internal members of the health care team on case management and managed care concepts; facilitates integration of concepts into daily practice.
- Provides education, information, direction and support to patient/client family, caregivers, and multidisciplinary healthcare team members as it relates to the care goals for the patient.
- Maintains current knowledge of all regulatory guidelines and case management standards. Participates in internal/external continuing education and quality improvement activities.
- Displays proper etiquette and mannerisms that reflect the SHINE Behavior Standards.
- Promotes the Patient Safety Standards as a core value of the organization.
Secondary Functions:
- Participates in departmental and association-wide informational meetings and inservices, including staff meetings, association-wide forums, and seminars.
- Reviews department and association-wide policies and procedures annually.
- All other duties as assigned.
Job Scope:
This job involves a wide diversity of work situations, a high degree of complexity, and typical operation from established and well-known procedures. Contributes to the development of new services, programs, or processes. Performance under independently-minimal supervision.
Supervisory Responsibility:
Job is supervisory to the extent that daily work direction is provided to personnel in subordinate classifications. Decisions are made within prescribed operating guidelines.
Interpersonal Contacts:
Contacts are normally made with others both inside and outside the association, made with own department as well as other departments or locations. Frequently contain confidential/sensitive information necessitating discretion at all times. Are made via telephone, e-mail, and face-to-face interaction with staff, patients, and physicians.
Specific Job Skills & Mental Activities:
This position requires a working knowledge of clinical and financial operations at the point of care, including utilization and clinical resource management. This position requires operational knowledge of all equipment in the Care Resource Management department, including fax, printers, copy machine, phone systems, and commonly used association-wide computer programs (including Hospital Information Systems, MS Office, e-mail, and internet). This employee must be service oriented and have excellent customer service skills, computer skills, critical thinking skills, problem-solving skills, organizational skills, multitasking skills, professional interpersonal skills, time management skills, the ability to prioritize work, the ability to work in a team, and telephone etiquette. Broad-based knowledge and clinical expertise in assessing, analyzing, intervening, and evaluating patient care. Must read, write, speak, and understand English.
Education and/or Experience:
- Current AZ RN license (required).
- BSN Degree (preferred).
- Basic computer skills (required).
- BLS/CPR certification (preferred upon hire; required within 30 days of hire)
- Two years nursing experience (required), acute care experience (preferred).
Physical Demands & Job Conditions:
Exert up to 20 lbs. of force occasionally, and/or up to 10 lbs. of force frequently, and/or a negligible amount of force constantly to move objects. Physical demands are in excess of those of sedentary work. Light work usually requires walking or standing to a significant degree. The worker is exposed to extensive computer work and encounters with upset individuals. Physical motions include finger dexterity, standing, walking, stooping, talking, reaching, feeling, sitting, bending, kneeling, grasping, listening/hearing, handling, lifting up to 10 pounds, and repetitive motions of the hands, wrists, and feet. This is considered a safety sensitive position.
OSHA Exposure Category:
Involves no regular exposure to blood, body fluids, or tissues, and tasks that involve exposure to blood, body fluids, or tissues and are not a condition of employment.
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