Job Description

JOB TITLE: Case Manager (Transitional Care, Utilization Review, Discharge Planner, Social Services)

DEPARTMENT: Case Management

REPORTS TO: CNO


SUPERVISES: Activities Therapist/COTA

Position Summary:

The Transitional Care component of this job is responsible for evaluating patients for admission to the Swing Bed Program and ongoing utilization review of Swing Bed patients.


Demonstrates professional development/clinical competency; assists in the training and education of personnel Interacts as a liaison person with the Medical Staff, Therapies, Chief Nursing Officer, Nursing Department and all other departments regarding the long-term care patient and the coordination of care. Participates in multidisciplinary planning including the discharge process. Acts as an advocate for the patient. Actively seeks patients that would benefit from Transitional Care services.

The Utilization Review component involves performing admission and continued stay reviews on all patients and reporting to utilization management agencies (as required) using approved criteria for effective evaluation of the need for hospital level of care and appropriate use of hospital resources.

Performs pre-admission reviews and consults with physician concerning patient stays Utilizes patient care guideline software to determine appropriate patient status Interacts with the Business Office and the CFO in regards to payment issues involving patients.
The Discharge Planner component involves working with the patient, their family, the provider, and other departments and/or outside agencies to facilitate a smooth and safe transition from hospital/transitional care to home.

Works with patient and family to develop plan for transition to home Facilitates follow-up appointment. Works with Therapy and Nursing to arrange for receiving home care or DME needs.

The Social Services component involves providing support to patients and family members during times of crisis as well as acting as liaison between the various healthcare disciplines and the patient and/or patient's family

Intervenes in situations where patients and/or their families have complaints or concerns Works with others to resolve these issues in a positive manner.
POSITION RESPONSIBILITIES

ESSENTAIL FUNCTIONS:

Responsible for the effective and efficient operation of the Transitional Care program ensuring that the organizational and departmental objectives are being met. Conduct on-site reviews of potential Transitional Care referrals whenever possible. Builds and maintains a strong working relationship with the physicians. Acts as a resource to the physicians. Uses recognized/appropriate patient care guidelines to assist with care decisions being made by the physician. Teaches others (Physicians and Nursing) how to access and utilize the patient care guidelines. Acts as a resource to the ED physicians and ED staff in determining appropriate patient status (inpatient; observation; etc) for those patients being hospitalized from ED. Builds and maintains strong working relationships with peers from other facilities. Collaborates to achieve and maintain a high swing bed referral rate. Uses these opportunities to promote PR for our organization and the services we offer. Document UR/Case Management activities such as precertification, concurrent and retrospective reviews on all patients. Assess patient and family needs by reviewing the admission assessment including history and physical and ongoing assessments including safety, infection control, and health education needs. Utilizes documentation skills to accurately complete patient/unit forms and records. Intervenes as appropriate in mental and/or physical patient crisis situations. (i.e. patient falls, combative behavior, etc.) Consults regularly with other staff and physicians to review treatment plans when level of clinical care requires further clarification. Assists with training and orienting of new departmental staff as needed. Ensures that new staff members receive adequate instruction/training when assigned to the department. Acts as a resource person to the unit staff and provides appropriate and timely feedback concerning their performance. Works cooperatively with others. Has respect for and an understanding of the contributions of all team members. Assists in maintaining established departmental policies and procedures, objectives, quality improvement program, safety, environmental and infection control standards. Ensures staff compliance with these standards. Assists in maintaining departmental reports and records and collects statistical data for administrative and regulatory purposes as directed. Assists in implementing unit specific goals and objectives in keeping with overall organizational goals and objectives. Assists in maintaining adequate and effective communication between the physicians, nursing staff, therapy departments and ancillary departments for the purpose of problem solving and improved patient care processes. Interacts with others (on the phone or in person) in a positive, professional and appropriate manner. Utilizes appropriate lines of communication within the nursing department; with other departments and with physicians. Ensures that appropriate care standards and practices are met. Consults with others as required and adjusts nursing care processes as indicated to ensure optimal patient care and patient outcomes. Attends required meetings and actively participates on organizational committees. Promotes professional staff development. Promotes a safe environment that allows for the delivery of high quality patient care. Protects patient confidentiality by demonstrating, promoting and enforcing appropriate staff communication practices. Ensures practitioner orders are carried out using sound nursing/therapy judgment. Maintains and utilizes a workable tracking system and clear, concise records for monitoring and reviewing cases. Prepares documentation/case synopsis upon closure of cases as needed. Supports and is involved in the hospital's quality improvement initiative and activities. Coordinates discharge needs regarding all patients early in the hospitalization. Provides information to patients and families about types and costs of services available to them to enable them to make informed decisions. Acts as liaison with nursing/medical staff and community agencies to facilitate problem solving and coordination of services. Works with Business Office Personnel to regarding authorizations, denials, appeals and retroactive reviews on inpatient, observation and swing beds. Assess patient's needs for intervention by other disciplines (i.e. OT, ST, PT, etc) Works closely with other disciplines (i.e. OT, ST, PT) to assure patient needs are being met. Reviews Medicare, Medicaid, private insurance, assigned self-paying patients, and other patients' records whose third-party coverage requires precertification and concurrent monitoring and reporting to designated utilization management agencies to assess medical necessity for hospital level of care and appropriate use of hospital resources. Reviews all readmissions in an attempt to determine reason for readmission and whether future readmissions are preventable. Issue Advance Beneficiary Notices according to the Center for Medicare and Medicaid guidelines, when applicable. Follows appropriate procedure for issuing Termination of Benefits letter when referred case is denied by physician advisor with concurrence of attending physician or by PRO. Visits all nursing units and abstracts pertinent data from designated medical records. Admission reviews are performed within 24 hours of notification of admission (exclusive of weekends and holidays); extended stay reviews are performed at least by the dates of expiration of the previously assigned length of stay. Completes monthly statistical reports in a timely manner and submits reports to the appropriate person. Provides patient/family information when needed on topics related to Medicare, Medicaid, Private Insurance, KCHIP, long term care requirements, etc. Acts as a resource concerning these matters. Acts as a resource to the patient and family concerning Advanced Directives, Guardianship, etc. Assists in accomplishing these. Demonstrates an understanding of the financial impact to the organization of various components of the Case Manager role. Demonstrates cost conscious attitude toward staffing, supplies and departmental function and operation. Refers questionable cases in which medical record documentation does not support approved criteria to physician advisor members of the UR Committee for a decision regarding justification of medical necessity for admission or continued stay. Notifies the attending physician of the need for additional documentation in the patient record when criteria are not met on admissions within the required time frame. Keeps up to date with Medicare, Medicaid, The Joint Commission regulations and requirements along with the pre-certification concurrent review monitoring requirements for the various utilization management agencies/insurance companies - particularly those with whom the hospital has a contractual agreement to help insure reimbursement. Insures that all regulatory guidelines for UR and Transitional Care Program are met and consistently followed. Delegates appropriately to the Activities Therapist. Supervises monitors and evaluates the Activities Therapist job performance. Notifies the Activities Therapist of needed or cancelled visits to Transitional Care Patients as census changes. Must be self disciplined; self starting and be able to function independently with varying degrees of oversight. Must possess and utilize strong "people" skills and a strong degree of professionalism while interacting with others. Performs other duties as assigned.


MINIMUM EDUCATION:


Associate Degree in Nursing with a license to practice in the state of Kentucky.

MINIMUM EXPERIENCE:


1-2 years experience in nursing.


PREFERRED EXPERIENCE:


2-4 years experience in nursing. Previous experience with Case Management, UR, and Transitional Care related duties

MANAGEMENT EXPERIENCE


Prefer previous management experience.


Excellent human relations and oral/written communication skills.