Case Manager, Full Time, Days, Preadmission Screening Unit
Department: Case Management - 716900
Position Type: Regular
Shift: Day Shift
Hours Per Week: Full time 30 hours per week
Location: New England Baptist Hospital, 125 Parker Hill Ave, Boston, MA 02120
Primarily assigned to the Pre-Admission Screening Unit (PASU), the case manager provides initial assessment, screening and ongoing review of the anticipated clinical course to all patients who are identified as high risk or referred to the case manager. Identifies case management needs in collaboration with the interdisciplinary team and initiates a plan to develop, manage and evaluate integrated patient delivery systems. Utilizes clinical experiences and expertise in conjunction with the managed care environment in collaborating on clinical interventions and addressing resource utilization issues. Demonstrates critical thinking and creative problem solving by collaborating with members of the interdisciplinary team.
As a member of the Case Management department, manages patient care through the continuum by facilitating the achievement of optimal outcomes in a cost-effective manner. Negotiates, procures, monitors and coordinates services and resources needed to reach the identified goals. Continuously evaluates the effectiveness of the case management plan with the physician and rest of the healthcare team and modifies as needed. Communicates with the patient, family and healthcare team regarding progress on plan. May be required to perform other duties based on operational needs, including covering medical/surgical units.
Principal Duties and Essential Functions
- Screens elective admissions in the PASU and develops an initial working discharge plan in conjunction with the patient/ family /interdisciplinary team, prior to the patient presenting for their procedure.
- Identifies any psychosocial, financial, or other concerns that may affect patient care management and works with patient/ family/ interdisciplinary team to develop a plan that addresses potential barriers to a successful recovery and transition of care.
- Serves as a resource to the interdisciplinary team for community-based social service agencies.
- Assesses patient's/ family's ability to provide for the patient's post-operative care needs and makes appropriate recommendations and referrals.
- Department Specific Responsibilities:
Patient Care Management:
- Screens all patients referred to Case Manager for appropriate management and plan development.
- Collaborates and participates with unit and/or specialty based clinical nurse specialist, the primary nurse and physician in the ongoing clinical assessment of patient's status and care management.
- Serves as the leader of the Med/Surg/Ortho Case Management Team and directs/utilizes Resources to ensure quality outcomes for the patient by performing the following:
- Confirms demographic information with patient/family.
- Determines necessity of intervention and appropriate level of care.
- Develops plan of care in conjunction with the healthcare team.
- Provides emotional support to the patient/family during patient's illness in conjunction with the medical and nursing staff.
- Utilizes appropriate resources to optimize patient outcomes; such resources include but are not limited to rehabilitation, respiratory care, dietetic, ElderCare and other clinical services.
4. Utilization Management/Managed Care
Coordinates and organizes a timely and accurate review of each medical record for severity of illness and intensity of service thus satisfying state and federal regulations encompassing:
- Works with MD offices to assure Compliance with entry requirements within each payor source.
- Works with Admitting to insure Appropriate setting and requirements.
- Provides clinical information as necessary to obtain Authorization for acute inpatient care.
- Monitors and manages the utilization of observation services at NEBH.
- Verifies patient admission information for each assigned patient within 24 hours of patient's admission and determines patient's appropriateness for acute hospital level of care.
- Monitors patient's clinical course to verify patient's continued need for acute hospital level of care as required for assigned patient population(s).
- Provides third-party payors with concurrent review information as needed to comply with payors' requirements for documentation of medical necessity and negotiates resolution of any disagreement over the need for acute hospital level of care if and when this is appropriate.
- Intervenes with the appropriate parties regarding inappropriate admissions and delays in discharge.
- Responds to patient questions regarding inappropriate admissions and delays in discharge.
- Intervenes with appropriate individuals/departments regarding delays in service that may have an impact on quality of patient care and/or length of stay.
5. Discharge Planning
In collaboration with the Social Worker, the Case Manager is responsible for directing and utilizing resources for discharge planning
- Determines the level of care required for post discharge services and the linkage to existent community/health services.
- Serves as a resource to the inter-disciplinary team for discharge planning options and assessing the financial impact.
- Provides clinical information to third party payors to certify the need for post discharge services and negotiates coverage for appropriate post discharge services.
- Reviews patient admission information for assigned case load and determines anticipated length of stay and discharge plan and begins discharge planning process in collaboration with the interdisciplinary team, patient and family.
- Prepares documentation regarding level of care if this is necessary for discharge planning.
- Interacts with home care agencies and facilities to ensure safe and timely discharge as needed.
- Ensures follow-up contact with patient/family and community agency or facility to evaluate the effectiveness of the discharge plan.
- Ensures coordination of the communication process with patient/family concerning the discharge plan including coordination of family meetings.
- Identifies and addresses system issues and makes recommendations.
- Removes barriers and makes recommendations.
6. Quality Improvement Activities/Variance Tracking
Directs data collection services:
- Participates in quality improvement activities designed to evaluate the appropriateness and effectiveness of the service delivery system in which case management operates.
- Participates in the development or revision of hospital policies pertaining to admission, discharge and patient care processes.
- Collects and analyzes variance data to identify opportunities for improvement in hospital-wide systems for the delivery of patient care re: LOS, cost, practice patterns, charges and efficiencies or lack thereof, current trends and analyze reports.
- Provides data for the Utilization Review Committee.
Under the direction of the Service Line Administrator and in collaboration with the Case Management Coordinator.:
- Analyzes data and make recommendations to change medical practice to enhance efficiency.
- Acts as liaison between fiscal and clinical areas and provides data to maximize reimbursement.
- Communicates, collaborates and maintains effective working relationships with the healthcare team regarding the appropriate utilization of acute inpatient hospital services and development and actualization of the discharge on a daily basis.
- Ensures that the patient and family receive consistent information regarding anticipated length of stay, treatment plan and discharge care plan.
- Maintains effective working relationships with insurance representatives as well as agencies and facilities that provide post-discharge services.
- Communicates and collaborates:
- To ensure that case management needs of assigned patients are met without duplication of efforts.
- To ensure adequate documentation in the patient's medical records on a daily basis.
- To ensure appropriate individual(s) or group(s) address systems or practice patterns identified through variance data analysis as necessary.
a. Maintains Current Knowledge of:
b. Managed care requirements for inpatient utilization of services.
c. Community resources including home health agencies, chronic/rehabilitation hospitals, skilled nursing facilities, home infusion and durable medical equipment vendors and special service providers.
d. Criteria for all levels of care.
e. Federal, state and private insurance rules and regulations as they relate to patients.
f. Education Resource
g. Patients and families on the concept and process of managed care as well as the concept, process and goals of case management.
h. Hospital staff on the concept, process and goals of case management at NEBH, importance of medical record documentation in meeting standards of professional practice and to ensure optimum communication and reimbursement.
i . Members of the interdisciplinary team on managed care requirements and their implications for patient care.
j. Prevention of illness and health maintenance.
k. Maintains current knowledge of case management process and patient care costs relative to reimbursement.
l. Participates in the evaluation and effectiveness of community resources utilized for providing home health and other discharge services.
- Professional Development:
a. Meets continuing education requirements to maintain licensure in Massachusetts.b. Attends continuing education programs pertinent to specialty care.
c. Pursues continuing education opportunities in case management concepts and practice.
d. Maintains membership in pertinent professional organization(s).
11. Plans time away from work appropriately
- Arrives and leaves at designated times.
- Uses unplanned earned time appropriately (Based on full time hours. Standards are pro-rated for part-time employees based on agreed hours).
12. Performs other duties as required based on operational needs, including covering medical/surgical units.
13. Attends annual safety review
KNOWLEDGE, SKILLS, AND ABILITIES:
- Graduate of an NLN accredited school of nursing, BSN required
- Five to seven years in case management in acute hospital setting strongly preferred.
- Experience in quality improvement and/or case management, discharge planning or utilization management experience required or strongly preferred.
- Demonstrated leadership and management ability
- Demonstrated ability in and knowledge of complexities in managing patient across the continuum of care
- Strong collaborative team skills
- Demonstrated knowledge and ability in the intricacies managed care and reimbursement
- Strong interpersonal skills
- Advanced analytic, writing and speaking ability to meet all responsibilities
- Grasp of learning theories and teaching techniques
- Computer skills including e-mail and word processing
LICENSE, CERTIFICATION REQUIRED: Current licensure as a registered nurse in Massachusetts. BSN required.
3 Years previous direct patient care, Case Management/Utilization review, current AHA Heartsaver or BLS required, CCM or ACM desired but not required