The Case Manager is responsible for assessing patient/family psychosocial needs, planning, implementing, and evaluating care for patients across the health care episode. Ensuring delivery of cost-effective quality care within an appropriate length of stay. Managing patient care to prevent fragmentation and duplication of services. Working in collaborative practice with the physician and other health care team members to meet patient-specific and age-related patient needs, linking cost resource management and quality to patient care. Other related duties as assigned.
ESSENTIAL/PRIMARY JOB SPECIFIC RESPONSIBILITIES:
• Maintains PHI and HIPAA for each patient in accordance with hospital policy and federal regulations.
• Promotes safety in the workplace and a safe patient environment at all times
• Practices “minimum information necessary” when performing UR, case management, and discharge functions
• Acts as a patient advocate for all facility patients
• Adheres to all company and professional, ethical, legal, and accreditation/regulatory standards
• Respects and promotes individual patient privacy and confidentiality
• Demonstrates knowledge and support of the organization’s mission, vision, values, and strategic initiatives.
• Demonstrates an understanding of and upholds the organization’s Quality, Risk, and Continuum of Care program philosophy.
CASE MANAGEMENT RESPONSIBILITIES (75% of time performing duty)
• Completes all initial psychosocial assessments in the initial case management treatment plan within two (2) business days from the date of admission.
• Admission medical necessity review using InterQual criteria will be completed within two (2) business days of admission and will be based on medical record documentation on the chart within 48 hours of admission and document using the appropriate UR form.
• Completes ongoing concurrent and discharge UM reviews at least every seven (7) days. All UM reviews will be documented per policy. UM, the process for referral of cases to Physician Advisor/Medical Director will be followed when appropriate.
• Initiates and facilitates the Initial Multidisciplinary Team Conference within seven (7) days of admission. Ongoing Team Conferences are held on each patient every seven (7) calendar days.
• Works in coordination with the multidisciplinary team to initiate a treatment plan, identify goals and interventions and establish discharge plans appropriate to medical, legal, and social issues present in accordance with patient/family needs.
• Participates in weekly UM meetings to review all DRG outlier cases for appropriateness of admission and discharge and need for continued stay. Barriers are identified, and appropriate physician intervention is obtained when necessary.
• Completed all UM reviews within stated time frames and follows UM process for additional clinical reviews when necessary.
• Provides clinical updates to third-party payors after admission within stated time frames to obtain continued stay authorization. All interactions and results of interactions with third-party payors are documented in the Meditech system. This documentation includes- Level of care, rates, number of days approved, and date the next review is due.
• Provides case management, utilization management, and discharge planning equally to all patients regardless of payor source.
• Maintain all case management documentation in the chart in a timely fashion, so all team members are aware of ongoing discharge planning progress or issues.
• Works collaboratively with all external third-party payors to coordinate patients’ medical management’s timely implementation and assist with case management functions across the care continuum.
• Assists in ensuring PA and Medical Directors document interventions and results of interventions timely and appropriately.
• The case manager also updates this data in Meditech and communicates any changes timely to third party payors to update authorization of ongoing medical care appropriate to patient needs.
• Uses DRG and InterQual as tools to assist in appropriate patient medical services management and facilitate discharge to the appropriate level of care in the most timely and cost-effective manner.
• Assists in obtaining legible physician documentation in the medical record to support current treatment, medical necessity of continued stay, and documentation of all current diagnoses being actively treated. Specific treatment of these diagnoses should also be documented to define further the need for continued acute care and medical resource use.
• Ensures timely consultations with specialists, specialized services, or critical diagnostic tests are completed and results obtained to facilitate timely medical treatment implementation.
• Collaborates with the treatment team and patient/family to prevent duplication or fragmentation of services.
• Conducts concurrent and retrospective reviews to identify and improve clinical, resource, and system problems utilizing the continuous improvement process.
• Ensures and facilitates patient education as necessary to meet specific patients’ learning needs and ensure safe discharge.
• Consults assists and intervenes regarding the end of life for patients
• Reports, coordinate with, and maintains APS/CPS logs of potential abuse and neglect for all patients in accordance with Federal, State, and organization policies. This information is shared with Quality, who maintains the APS/CPS logs and assists with necessary follow up as appropriate.
• .Provides and maintains resource lists for patients and staff regarding financial and community resources for all age populations served.
• Provides a list of community resources to patients/families for discharge placement, DME, Home Health services, and other community resources when appropriate and when specifically requested by patient/family members.
• Promotes interdepartmental communication and collaborative problem-solving in relation to discharge planning needs and discharge plan.
• Actively coordinates and finalizes discharge plans to ensure smooth and timely discharge of patients with all appropriate services and equipment in a safe environment appropriate for patient/family needs.
• Appropriately documents the progress of discharge plans and services in multidisciplinary progress notes to ensure communication of status is available to all team members. Follows all policies on documentation.
• Identifies/tracks/trends/analyzes selected variations (variance=patient/family, practitioner, system or community) which affect patient care, resource management or length of stay. Completes statistical and other reports as required in a timely manner.
• Ensures utilization of medical resources for patients efficiently and effectively
• Maintains a safe environment
• Participates in Quality Improvement, UM Committee, and Risk Management as indicated
• Attends department meetings and mandatory in-services’. Reads all communications
• Completes all Discharge documents for every patient to include: Patient Discharge Satisfaction Survey, Discharge Instructions, and final discharge case management note in multidisciplinary progress notes in accordance with all established policies and procedures.
• Performs other duties as assigned.
• 3-5 years’ experience in acute hospital direct care
• 2-3 years’ experience in acute hospital case management, utilization management, or discharge planning of complex medical/surgical cases
• Proficient with use of InterQual, Milliman, or other national recognized criteria
• Strong analytical and organizational skills
• Working knowledge and ability to apply professional standards of practice in the work environment.
• Knowledge of specific regulatory managed care and accreditation requirements
• Computer proficiency
• Registered Nurse, Licensed MSW, or LVN with an active, unrestricted license in the State of Texas
• BSN preferred
• Must maintain current licensure in good standing during employment in Nursing or Social Work
• Certified in AHA BLS/CPR
• Must obtain CEU’s in accordance with state requirements for licensure