Specific Duties and Responsibilities:
Care Coordination, Collaboration and Facilitation.
The emphasis is on care coordination and positive partnerships with multiple disciplines (clinical and non-clinical) in order to pace the care toward optimal outcomes within the appropriate level of care.
- Collaborates with the interdisciplinary team; participating in team rounds to:
- Facilitate timely care
- Assure quality of care throughout the hospital stay, minimizing adverse outcomes.
- Initiates appropriate referrals to the internal interdisciplinary team.
- Communicates with Admitting or PFS regarding the needs of the patient, payer and provider.
- Communicates relevant elements of the patient’s health plan benefits.
- Understands the target LOS on every patient at the time of the initial review and identifies the anticipated date of discharge for planning and care coordination purposes.
- Maintains an open line of communication with other disciplines regarding the target LOS and anticipated discharge date.
- Documents all team, physician and patient/family communication and concerns pertaining to coordination of care and services.
- Participates in unit bed huddles and/or multi-disciplinary rounds.
Utilizes the nursing process to conduct a thorough assessment of discharge needs, beginning at admission and as care needs evolve. The goal is to assure a seamless and safe patient transition to the most appropriate level of care that has the identified resources to meet the medical, nursing and psychosocial needs of the patient. The RN Case Manager collaborates with the interdisciplinary team in the identified plan for referral, transfer or discharge of the patent to another level of care.
- Develops and effectively utilizes a network of information regarding community resources.
- Coordinates the discharge planning process in collaboration with other professional members of the interdisciplinary team.
- Appropriately delegates within the scope of practice, discharge planning activities and functions to others involved with discharge planning; case manager associates or other non-licensed personnel performing discharge activities.
- Identifies the appropriate level of post hospitalization care and services required.
- Develops the post-hospital plan of care with the patient and family, the clinical team, and external resources.
- Communicates and documents discharge planning needs.
- Provides necessary patient teaching relevant to discharge needs and/or post hospital care arrangements prior to discharge.
- Assesses the patient prior to discharge to determine if the plan is appropriate and makes necessary revisions
- Keeps the interdisciplinary care team informed regarding details of the discharge plan.
- Communicates essential information to the next care provider.
Consistently applies the utilization management process as required by the Code of Federal Regulations, including the use InterQual Evidenced Based Medical Necessity criteria for primary review. Incorporates into the utilization management process the ability to access and interpret clinical information against InterQual Evidenced Based Medical Necessity criteria to reach correct admission status determinations. Has the current knowledge of applicable regulations and laws pertaining to the major payers including Medicare, Medicaid, and other payers. Works with the interdisciplinary team to ensure that the care and services provided are medically necessary, delivered efficiently and timely, and at the appropriate level of care to meet payer requirements and established financial and performance benchmarks.
- Completes medical necessity utilization reviews and documents those reviews in MIDAS+ within required timeframes
- Reviews every admission and observation order for appropriateness based on InterQual criteria within the required timeframes and follows the approved utilization review procedures if the patient status order is not consistent with the medical necessity assessment.
- Notifies Admitting Department of errors or needed changes in patient data including changes in physician orders/incorrect admission status designation.
- Coordinates internal and external services to avoid under or over utilization of resources.
- Facilitates or participates in interdisciplinary team meetings or rounds.
- Reviews record including physician orders and documents admission, concurrent, discharge reviews and retrospective reviews as assigned.
- Communicates with physicians regarding the level of care or admission status when appropriate criteria are not met for inpatient, observation or continued stay.
- Refers cases to the Case Management Medical Director as needed and documents the referral.
- Identifies avoidable delays in care or delays in discharge, attempts to resolve delays and document identified avoidable or denied days in MIDAS+ on a daily basis
- Provides and documents concurrent reviews or other information requested by the payer within required timeframes.
- Initiates the appropriate letter (HINN: admission or continued stay, ABN) for any Medicare beneficiary if the outcome of the Physician Advisor secondary review indicates that the patient does not meet inpatient admission/observation status or continued stay medical necessity criteria.
Professionalism, Quality, Growth and Safety
Employees will conduct their job functions in a manner consistent with their professional licensure and will demonstrate willingness to learn, improve, grow and achieve.
- Demonstrates responsibility for professional development and growth including identifying continuing education needs and seeking learning opportunities that will enhance job performance and professional satisfaction.
- Effectively organizes work priorities.
- Demonstrates compliance with facility and departmental safety and security policies and practices.
- Educates hospital team members and physicians about the Case Manager Role and scope of RN practice.
- Supports the hospital quality, risk and performance improvement programs.