RN Case Manager

Job Type
Full-time
Description
Position Summary:
The RN Case Manager collaborates as part of the critical access hospital health care team to assess the patient's plan of care and expected outcomes with special attention being given towards the progression of discharge services.
Analyzes patient records to determine legitimacy of admission, treatment, and length of stay to comply with government and insurance companies' reimbursement policies. Oversees the admission process including the initial nursing assessment and plan of care. Works collaboratively with the Providers and clinical staff to identify current standards of practice, educations and research to meet evidenced based practice and regulatory requirements. Takes action to improve the effectiveness of clinical practice and outcomes of care.
Essential Functions:

• Ensures the model components of screening, assessing, evaluating risks, planning, and implementation, follow up and outcomes driven program coordination
• Functions as the Case Management RN for overall care coordination for the entire organization
• Available off hours for phone calls from providers/staff regarding patients (occasionally)
• Performs concurrent and retrospective record review to ensure compliance for patient classifications: Observation, Inpatient, SWINGBED, and Outpatient Procedure (in the inpatient setting)
• Obtains authorizations and pre-authorization for inpatient, observation and test/procedure ordered to ensure hospital requirements are met for the specific insurance
• Acts as hospital resource for participation with Medicare/Medicaid and Peer Review Organization to ensure feedback has been provided to Providers for necessary documentation regarding reimbursement requirements
• Issues CMS forms as appropriate
• Direct discharge planning process (home care needs) with health care team in support of treatment adherence and medication compliance; assist with transitions for patients discharged from hospital setting to alternate home care environment
• Oversees follow up with discharged patients to ensure compliance with discharge plan and identification of care issues for resolution
• Evaluates referred patients' appropriateness for acceptance into the SWING bed program
• Accepts referrals for evaluation using the SWING bed Intake Form: o SWING admission status SWING or SWING Intermediate
• Compare medical record information to established criteria and confers with the health care team to determine ability to meet treatment goals and length of stay
• Evaluates Senior's/client's medical information to determine Medicare, Medicaid, and private insurance reimbursement issues, and acts on issues as identified
• Provides information to Senior/client/families regarding financial concerns, including general information regarding Medicare, Medicare Part D, and application for Medicaid and other financial assistance programs
• Available to assist community members with Medicaid application process

Non-Essential Functions:

• Perform other duties as assigned or requested.

Supervisory Responsibilities:
None
Work Environment:

• The employee will primarily work in an office setting.
• The noise level in the work environment is usually low to moderate.
• The employee may occasionally need to visit other areas within the facility or external locations for meetings or other work-related activities.

Physical Demands:

• The employee is regularly required to sit for extended periods, use hands to handle or feel objects, tools, or controls, and talk or hear.
• The employee is frequently required to stand, walk, reach with hands and arms, and stoop, kneel, crouch, or crawl.
• The employee must occasionally lift and/or move up to 50 pounds.
• Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
• The employee may need to push, pull, or move objects and equipment, occasionally weighing up to 50 pounds.
• The position may occasionally require physical activities such as walking and standing for extended periods during meetings or other events.

Qualifications:

• Current NE State License as a Registered Nurse required or ability to obtain
• CMGT-BC - Nursing Case Management Certification from the American Nurses Association or the ability to obtain within
• Approximately three-five years progressively more responsible clinical work-related experience
• Professional knowledge of nursing practice, and regulations to support patient care delivery, evidence-based practice, utilization review and case management
• Interpersonal skills necessary effectively communicate with a wide variety of hospital personnel, community residents, and outside agency personnel
• Analytical skills necessary in order to develop and prepare special and recurring reports or analysis
• Current BLS, ACLS, PALS or ability to obtain within 2 months of hire
• Current TNCC or ability to obtain within 9 months of hire
• Job functions must be performed on site with regular attendance

Security/Access:

• Will have access to facility 24 hours a day
• Will have access to confidential information abiding by the organization's privacy policies and regulations concerning this information
• All Harlan County Health System users will be given access to the organizations network to the level required to perform their specific duties. Some users will require access to job specific systems, the authorization of these systems will be granted but the department director or the IT coordinator.

Patient Age Groups Served:

• All

Other Duties:
The above statements reflect the general details considered necessary to describe the essential functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position. Duties, responsibilities, and activities may change, or new ones may be assigned at any time with or without notice.