Case Management Nurse

Job Description
Overview

The Case Manager has a day-to-day responsibility for assessing the medical necessity of patient admissions, and continued stays, based on the clinical documentation in the Electronic Health Record (EHR) in accordance with Milliman Care Guidelines (MCG). The Case Manager assists in coordination of care among multidisciplinary team members such as Medical Attending’s, Residents, Interns, Specialists, Social Workers, Nursing, Dietary, Finance, and Clerical staff.

Case managers identify triggers to re-admissions and needed community/social/financial support to maintain appropriate and safe discharges related to ongoing medical management of patient care needs.

The goals of the Case Management services are to identify Physician and staff documentation opportunities to support Quality and Pay for Performance indicators and execute prudent and sequential care by bringing about awareness to all treatment team members on length of stay reduction, and advocacy for compliance to plan of care.

Responsibilities

Case Managers are expected to have strong clinical backgrounds, and advocate for safe, timely adherence to executing the patient plan of care. Job training is available in addition to meeting the core qualifications for this position.

Performs face-to-face visits with patients that need assessment of physical, mental, and emotional barriers that prohibit self-care, prompt medical management assistance in the community, and initiation of referrals to social work by using nursing clinical judgment
An interdisciplinary care team member responsible for daily EHR review of patient’s medical necessity (severity of illness and intensity of service); either in bedside rounds, or Interdisciplinary team rounds
Collaborate with social workers on identification on any social determinants of health domains, that could impede patients’ health outcomes
Functions as a liaison between Physicians and Physician Advisors
Demonstrates the ability to correlate medical necessity (severity of illness and intensity of service) in achieving financial and quality care outcomes
Monitors the electronic health records (EHR) daily or as needed, for assigned patients, and complete clinical documentation pertaining to hospitalization for submission to insurance companies (Initial, Concurrent or Retroactive)
Reviews all HMO admissions for medical necessity and submit to HMO
Reviews admissions for medical necessity (severity of illness and intensity of service) within forty-eight hours of admission
Knowledge of Milliman Care Guidelines
Knowledge of CMS guidelines for post-acute plaements
Communicate with Attending Physicians on admission guidelines
Provide real time interventions to prevent delays and ensure compliance and revenue integrity with health care regulations
Informs treatment team members of recommended EHR documentation needed based on Milliman Care Guidelines for approval of admission, transfer, length of stay, and safe discharge planning
Identifies tests, procedures, and interventions early to advance the plan of care
Assess, and collaborate with the health care team the need for Alternate Level of Care designation. Document in EMR when patient is placed on ALC
Assess current support and adherence to medical care in the community, with the evaluation of effectiveness towards health promotion
Collaborate with treatment team members to create a care plan to reduce re-admission rates by identifying barriers to care and resolutions to those barriers
Responsible for completion of home IV infusion and related home care referral to IV infusion companies and follow up with patient/family
Responsible for completing wound vac and related home care referral for patients discharged home with wound vac
Makes appropriate referral to financial services prior to discharge · Discusses discharge planning with the treatment team to create PRIs prior to discharge
Document all activities in EPIC (submission of reviews, home care referrals, and completion of PRI’s) any correspondence conducted with the Insurance companies and or Home Care Agencies through Careport
Documents Case Management notes in a brief and concise manner
PRI proficient
Follow provider recommendations for discharge planning including facility placement to SNF/SAR/Acute rehabilitation and home with services
Arranges for community services prior to discharge to meet patient’s post discharge needs with recognition of patient’s choice of service providers
Updates and /or modifies the plan of care according to recommendations to facilitate safe and timely discharges
Communicates with Nursing staff the patients discharge plan
Knowledge of the discharge appeal process
Advocates for the patient/family with other health care disciplines and community agencies to facilitate the patient receiving the appropriate resources in the community
Mandated reported of suspected abuse in all patient populations (domestic violence, elder, child abuse, etc.)

Communication:

Strong written and verbal skills are demonstrated in reports, correspondence and presentations. Informed of medical center and departmental policies. Possesses the ability to negotiate and communicate with other disciplines, physicians practice groups, 3rd party reviewers and outside entities.

Professional Development:

Participates in conferences, workshops, and other professional development activities to maintain licensure and/or remain professionally current with advances in field of expertise. (JCAHO, Annual HIPAA/ Corporate Compliance, Mandatory Re-orientation training, BLS, ACLS, OSHA, and Fire safety). Adheres to the Case Management Society of America (CMSA) standards, and the Nurse Practice Act.

Professional Problem Solving:

Recommendations and decision making reflect strong analytical skills and focus on quality and cost containment, that impacts the financial status of the patient and the institution.

Customer Service Management:

Incorporates the medical center’s customer service goals in developing and/or revising departmental policies and systems. Continually reviews the service delivery process to exceed customer expectations.

Qualifications

Education:

Bachelor's degree in Nursing (BSN), required
Experience:

Minimum three (3) years clinical experience in one or more of the following:
Acute care
Medical-Surgical
Intensive Care
Emergency Department
Community Nursing (Home Care)
Licnese / Certification:

Current New York State Registered Nurse licensure, required
Basic Life Support (BLS) certification, required
Advanced Cardiovascular Life Support (ACLS) certification, required
Must maintain valid New York State Registered Nurse License, BLS and ACLS certifications throughout employment at One Brooklyn Health
Patient Review Instrument (PRI) certification, required
Pediatric Advanced Life Support (PALS) certificastion, preferred
Case Manager Certification (CCM), preferred
Knowledge, Skills and Abilities:

Knowledge of Federal, State and JCAHO guidelines for utilization review, discharge planning/quality assurance/infection control.
Physical Demands:

Involves occasional prolonged standing, walking, sitting, talking, hearing and bending
Must be physically mobile
May include some repetitive motions
Must be able to work well under stress
Must have good health and demonstrate emotional stability