RN Case Manager Home Hospital

Summary of Position The RN Case Manager (CM) facilitates a discharge plan including the coordination of post-acute care/services for patients admitted to Home Hospital. The CM may also oversee the coordination of care for both inpatient and outpatient of those patients identified as high risk for readmission. The CM will develop and implement discharge plans for those patients identified as needing post-acute discharge services or post-acute follow up in collaboration with the patient/legal representative, health care team/provider, insurer, and others, including community-based organizations, as needed. The CM uses a collaborative process of assessment, planning, facilitation, and advocacy. She/he may use a high-risk screening criteria or other acceptable screening tools to determine what patients may benefit from specialized care coordination services. The CM consults and collaborates with physicians regarding medical necessity of admissions and appropriate level of care for hospitalized patients utilizing nationally accepted criteria. He/she routinely reviews patients' health records and communicates with the health care team/provider to ensure continued appropriate level of care, compliance with Federal and State regulations related to discharge planning, compliance with CMS regulations or other third-party payers and appropriate utilization of hospital and medical resources. The CM completes timely and accurate insurance reviews as requested by third party payers. The CM will serve as a resource for physicians, hospital staff, and patients and their families in providing information about insurance coverage, limitations of coverage related to discharge planning, community resources, community referrals and post-acute care options. He/she participates in quality and risk management case finding activities. The role requires the ability to offer creative, problem-solving solutions using sound and prudent clinical judgment and within the scope of licensure and according to case management standards of practice. The CM seeks out educational and self-development opportunities related to care coordination, transitions of care, healthcare reimbursement, and other pertinent areas. Responsibilities Case Management Process * Patient identification and selection: Focuses on identifying patients who would benefit from case management services. * Assessment and problem/opportunity identification. * Development of the care coordination plan: Develops a plan and prioritizes the patient's needs, as well as, determines the type of services and resources that are available to address the desired outcomes. * Implementation and care coordination plan. Facilitates the plan in collaboration with others. * Evaluation of the plan and follow-up. Periodically evaluates the plan and revises as needed. Discharge Planning * Identifies patients who may require post discharge services utilizing high risk screening criteria, referrals, or other available resources. * Completes an assessment of patient discharge planning needs based upon medical condition including previous history, functional status, psychosocial support, living situation, and previous post discharge or homecare services. * Includes patient and/or family and caregivers in the discharge planning process through verbal and written communication. * Facilitates safe, effective, and efficient discharge plans in collaboration with the patient, the family, caregivers, the attending and/or primary care physician, nursing staff, other appropriate clinical staff, third party payers, and/or community-based care coordinators or other appropriate outside agencies. * Conducts ongoing assessment of the patient's health status, ensuring the patient is appropriate for the services/care provided and revising the post-acute plan as needed. * Ensures the implementation of the discharge plan including making facility/agency referrals and determining availability of services. * Ensures whenever possible, third-party payer approval of services needed for post-acute care. * Acts as consultant to physicians and hospital staff regarding resources, regulations, and reimbursement. * Documents the assessment, plan, and ongoing notes as part of the health record according to hospital and departmental policy. * Completes the case management sections of necessary discharge paperwork if applicable. * Facilitates the paperwork sent to post discharge service providers with the goal of improving transitions of care. * Participates in the planning, implementation, monitoring, and follow-up of patients either prior to or following hospital episode of care in collaboration with external healthcare providers including Primary Care Physicians, as well as, community-based organization. Utilization Management * Provides expert guidance to the medical, nursing, and rehab staff, as well as, other Hospital departments regarding Hospital criteria, insurance regulations, care coordination efforts, and discharge planning activities. * Performs admission and concurrent utilization management using Hospital approved criteria as a guide for determination of appropriate level of care. * Completes accurate insurance utilization reviews and obtains third party payer approval of services needed for post-hospital care as needed. * Identifies utilization management issues; analyzes, documents, and reports appropriately in accordance with hospital and departmental policies and procedures. * Identifies and intervenes in service delays and inappropriate utilization of health care resources using clinical knowledge, experience, accepted Clinical Practice Guidelines. * Identifies patients at high risk for readmission and influences enhanced care practices and/or other interventions. * Identifies methods to reduce readmissions, including increased oversight and communication with patients and providers in the community setting. * Participates in medical/utilization management activities for those patients whose health plan has delegated medical management to the Newton Wellesley Physician Hospital Organization. * Refers appropriate cases to the Physician Advisor, Physician Hospital Organization Medical Directors, and/or Department or Service Chiefs or Senior VP for Medical Affairs in accordance with departmental policies and procedures. * As delegated by Medicare or other third-party payers, delivers notices of Non-coverage and/or proposed insurance denials to patients/families according to payer, Hospital, and departmental regulations/policies. Quality /Performance Improvement * Participates in performance improvement measurements and initiatives including identification of variances/delays. * Participates in inter-departmental committees, focus groups, task forces, or other special projects as requested. * Identifies quality of care issues; analyzes, documents, and reports appropriately in accordance with agency and departmental policies and procedures. Regulatory Compliance * Demonstrates understanding and compliance with applicable standards, e.g. discharge and other standards as required. * Participates in on site visits or mock surveys. * Demonstrates knowledge about government regulations related to patient rights, confidentiality, and discharge planning. Other Duties * Participates in special projects such as audits, policy and program development, and other such duties as directed. * Participates and/or carries out other duties as assigned or requested. Skills/Competencies * Requires the ability to work independently and establish an effective relationship with physicians, office staff, and health care providers in physician's offices, community-based organizations, hospitals, and other health care facilities * Requires autonomy in decision making using sound judgment based upon factual information, clinical experience, and nursing process * Requires ability to seek out and identify resources to problem solve issues * Ability to work within a multidisciplinary environment * Requires ability to be cross trained for coverage of other RN CM assignments * Requires flexibility to cover assigned shift hours as determined by departmental need * Basic computer skills including knowledge of Microsoft products and efficient data entry ability * Effective written and verbal communication skills * Excellent organizational skills Requirements Education/Licensures/Certifications * Graduate of an accredited school of nursing. BSN preferred * Current licensure as a Registered Nurse in the Commonwealth of Massachusetts * Minimum of three years' clinical experience * Evidence of continued education and professional development. CCM or ACMA certification preferred Experience * Prior experience in the following areas: * general acute care hospital experience * healthcare reimbursement including utilization review * quality improvement * enhanced models of health care delivery * Previous acute care hospital care coordination/discharge planning required Working Conditions * Hybrid-Hospital-based environment, in an emergency department setting potentially 1-2 days a week