Reid Health RN-Case Manager in Richmond, Indiana
The Case Manager is accountable for the organization, sequence of services, and resources that are medically necessary and appropriate for the achievement of patient care outcomes within effective time frames. The Case Manager coordinates with the interdisciplinary team to expedite medically appropriate, cost-effective patient care. The Case Manager applies clinical expertise and medical appropriateness criteria to resource utilization, care coordination, and transition/discharge planning; advises the healthcare team, and provides intervention as needed to achieve optimal outcomes. The Case Manager applies the use of data in his/her practice; identifying where to focus efforts, the measurement of progress towards identified outcomes, and as an educational tool. This individual possesses excellent interpersonal, negotiation, influence, and organizational skills and works to effect positive practice changes that lead to improved value in patient care delivery.
Conducts utilization review/management as outlined in the UR Plan and assigned duties.
Performs initial review same day, no later than next day, evaluating patient’s condition and treatment plan for medical necessity, clinical appropriateness, completeness, and progression; Initiates transition/discharge planning.
Anticipates an appropriate length of stay based on the initial review and plans concurrent reviews accordingly.
Using established criteria reviews for appropriateness of continued stay and transition readiness ensuring all days are covered (approved for reimbursement). Accepts no pended days from payers.
Complies with all utilization review regulations and payer agreements. (e.g. Medicare Hospital Issued Notices of Non-Coverage, Detailed Notice of Discharge)
Facilitates the patient's plan of care in a proactive manner providing any necessary anticipatory guidance to the healthcare team members and patients/family.
Reviews the patient’s plan of care with the patient’s physicians, Social Worker, nurses, healthcare team, and payer (as applicable). Offers suggestions, coordinates care, determines the transition plan with the interdisciplinary team, identifies and resolves variances.
Works to avoid or overturns payer or internal denials concurrently by proactively resolving any clinical and operational barriers.
Works collaboratively with the Social Worker and refers complex home discharges and placements.
Utilizes the designated physician advisor(s) to address challenges, provide education, and address internal barriers.
Coordinates patient care conferences as necessary.
Serves as a consultant to staff, physicians, management and other health care professionals sharing knowledge regarding standards of care and best practices to ensure successful implementation of the patient’s plan of care.
Collaborates with all disciplines to address cost reduction opportunities related to use of resources.
Ensures timely execution of the patient’s discharge/transfer plan.
Documents appropriate interventions in the patient’s medical record and Case Management information system.
Collects, utilizes, and trends process and outcomes data for identification of problems related to efficiency and quality of care issues as directed.
Trends, analyzes, and reports outcomes, clinical process and variance data to appropriate audiences.
Participates in process and outcome improvement activities, such as protocol development, and helps facilitate approved practice changes.
For assigned population attends appropriate physician and Nurse leader meetings to report on trends, outcomes and statistics. Receives and acts on feedback from physicians and nursing management related to Case Management.
Achieves length of stay and resource consumption targets for the assigned patient population.
Performs other duties as assigned to accomplish the goals of the organization.
Education Required: Minimum of an Associate’s degree in nursing, Bachelor’s degree preferred
Experience Required: Minimum of 5 years’ experience required in a healthcare setting
Experience Preferred: Acute care nursing and case management /discharge planning experience preferred, knowledgeable of HFAP standards, government and private insurance benefits, e.g. Medicaid, Medicare, DRGs, managed care and working knowledge of clinical review guidelines
Requisition ID: 2021-7325
Street: 1100 Reid Pkwy