Summary: Role has multiple components: clinical, leadership, and educational. Major areas of accountability include utilization management, care co-ordination, discharge planning, and quality management. Goal is optimal patient care at appropriate level, in financially expedient and efficient manner. Inherent in this process is monitoring and tracking/trending of data. The Case Manager is responsible for monitoring of clinical documentation with guidance to physicians and extenders as needed. Compliance with all hospital COP’s
Utilization Management
Insures care delivered in fiscally responsible manner
Reviews inpatient, observation cases using nationally accepted criteria for appropriate level of care, discharge and continued stay
Reports exceptions, variances to Utilization Review Committee and/or responsible staff
Makes informed recommendations as to Level of Care, Length of Stay,
Documentation for medical necessity
Insures payer requirements met to insure payment for services rendered. Appeals as needed. Monitor for trends, patterns and refers to Utilization Review Committee or appropriate staff
Compiles, integrates information as needed
Participates in Utilization Review Committee as member
Acts as liaison with payers, CMS, QIO as needed
Co-ordinates and educates hospital staff as needed
Maintains current and up to date knowledge of current Utilization strategies
Case Management/Care Co-Ordination
Strives for efficient care across the continuum
Reviews continued stays using nationally approved criteria
Tracks/trends information and reports to Utilization Review Committee and appropriate staff
Assess patient for discharge needs
Coordination of discharge needs with personnel for DME, HH, and follow up
Insures payer requirements met for reimbursement
Participates in educational programs such as Joint Camp as needed
Is available for physician education/interaction
Discharge Planning
Considers, addresses and coordinates needs outside of facility
Assesses patient on admission or within one business day for discharge needs
Coordinates, arranges services as needed
Complies with payer requirements to maximize reimbursement for post discharge services and minimize cost to patient
Complies with federal and state regulations concerning financial interest disclosure and choice of provider
Compiles statistics and monitor for trends. Report as required to Utilization Review Committee and or responsible party.
Quality
Continues to promote quality healthcare as a means to the goal of patient satisfaction
Practices continuous vigilance for potential quality issues in all areas of expertise and all assigned areas
Addresses concerns in a timely manner and appropriate fashion. Compiles information and statistics.
Reports tracking and trending results to appropriate committee and department heads
Continues to maintain current information to facilitate recognition of quality issue
Maintains up to date information bank
Education and Experience
Degree or Formal Training: Associate or Bachelor's Degree in Nursing
License, Certificate or Registration: Current LA State Licensure
Additional Information:
BLS Required
Benefits are offered with this position after a waiting period.
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