POSITION SUMMARY: Provides overall coordination in the delivery of medical services and discharge planning for a specified patient population. Performs concurrent and retrospective review of patient medical records for purposes of utilization review, compliance with requirements of external review agencies including governmental and non-governmental payers and quality assurance agencies. Promotes a cooperative and supportive relationship as liaison with patient, family, facility staff, physicians, funding representatives and community agencies. Ensures continuity in the handoff of patient clinical information from the hospital to other involved healthcare entities. The duties of the acute care Case Manager may be performed as in the integrated or triad model. POPULATION SERVED:
All patients admitted to the hospital, emergency room, or outpatient areas and their families and/or caregivers. ESSENTIAL FUNCTIONS: 1. Financial Assessment and Coordination
a. Communicates proactively and cooperatively with Patient Access, Patient Account Services (PAS) and Central Verification Office (CVO) personnel to ensure proper pre-certification and consistency of admissions status designation between physician order and EMR.
b. Communicates known changes to patient payer information and other relevant financial characteristics of coverage to appropriate admissions and/or billing personnel.
c. Proactively ensures that required clinical justification is provided to third party payers to obtain recertification for continued hospitalization and treatment and that transfer of this information, together with days approved and contact information is provided timely to the PAS and CVO via computerized insurance review documentation.
d. Serves as liaison between third party payers, patient access PAS and CVO to ensure communication of all pertinent information regarding level of care, billing and reimbursement.
e. Works with the patient and family to identify alternate financial resources available to meet the cost of necessary post-discharge needs or to recommend alternate care options when necessary funding is unavailable.
f. Proactively initiates expedited appeals process with payers and communicates with denials management regarding anticipated or verified denials and cooperates with denials management to provide additional clinical information for appeals. 2. Treatment Planning and Coordination of Services
a. Educates patient and family on case manager role and process for contacting the case manager for questions.
b. Coordinates the integration of social services/case management functions into the patient care, discharge and home planning processes with other hospital departments, external service organizations, agencies and healthcare facilities.
c. Collaborates with clinical staff in the development and execution of the plan of care and achievement of goals.
d. Facilitates interdisciplinary patient care rounds and/or conferences to review treatment goals, optimize resource utilization, provide family education and identify post-hospital needs.
e. Ensures that patient tests are appropriate and necessary and are carried out within the established time frame and that results are promptly available.
f. Serves as a patient advocate by enhancing a collaborative relationship to maximize the patient's and family's ability to make informed decisions.
g. Refers to social work cases where patients and/or family would benefit from counseling required to complete complex discharge plans. 3. Utilization Review, Quality and Compliance Monitoring
a. Conducts concurrent medical record review using specific quality indicators and clinical decision support criteria as approved by the medical staff, TJC, CMS and other regulatory agencies and document findings.
b. Serves as liaison with Physician Performance Improvement (PPI) to ensure the reporting of quality indicators and care concerns.
c. Initiates delivery of notices of non-coverage as appropriate.
d. Reviews all new admissions daily against inpatient screening criteria and communicates necessary changes in status designation to ordering physician and Patient Access.
e. Identifies all observation patients with observation alert sticker, reviews status no less frequently than daily, and communicates directly with the attending physician if severity of illness and intensity of service meet criteria for inpatient admission or when observation hours threaten to exceed 48 hrs.
f. Communicates with treating physicians at regular intervals throughout hospitalization of the patient to develop an effective working relationship, while assisting physicians to maintain appropriate costs, utilization of resources, and discharge plans commensurate with the patient's available resources.
g. Ensures physician documentation supports medical necessity and LOC for each inpatient day, educates physicians by aggressively discussing additional documentation needs as identified or discharge plans and conferring with Case Management Director and Physician Advisor as needed for intervention.
h. Monitors and provides documentation of identified variance days for tracking and trending.
i. Stays current with education related to CMS and HCA billing compliance mandates, monitors and ensures that facility is compliant.
j. Facilitates delivery of CMS discharge appeals rights communication to applicable Medicare patients within indicated time frame required by law.
k. Provides retrospective chart review for short stay inpatients under Medicare for medical necessity and level of care prior to billing. 4. Discharge Planning and Continuity of Care
a. Collaborates with interdisciplinary care team, service liaisons, patient and family in the assessment and coordination of discharge planning needs, delivery of post-discharge services and transition of the patient from an acute level of care to the discharge setting.
b. Facilitates delivery of Patient Information and Choice Letter to assure documentation of patient/family involvement with discharge planning and choice of post-discharge service providers.
c. Facilitates the ordering and delivery of specialized medical equipment, orthotics and prosthetics as ordered by the attending physician.
d. Facilitates referral process of next level of care.5. General Duties
a. Attends twice weekly outlier meeting with Case Management Director and Medicaid Eligibility Vendor personnel to review observation admissions, extended LOS, unfunded and underfunded, and anticipated difficult discharges.
b. Attends and actively participates in monthly staff meetings, and attends called departmental meetings when necessary.
c. Attends and participates in facility committees, employee forums and departmental meetings as requested.
d. Actively utilizes and complies with facility principles of good communication and customer service standards, including use of AIDET as developed by the department.
e. Maintains compliance with required licensure, ethics and compliance training, annual mandatory TB screening and mandatory education as required.
f. Prepares and presents inservice and training programs as requested.
g. Performs other duties as required. PERFORMANCE OUTCOMES:
- Individual Leadership: Demonstrates confidence in own skills, knowledge and ability and opportunities for personal growth and ability to accept and adapt change.
- Customer Service: Demonstrates customer service skills with both internal and external customers.
- Transcultural Sensitivity: Treats patients/customers as individuals with unique values, beliefs, and practices.
- Risk Management/Patient/Customer Safety: Demonstrates patient/customer safety according to policies and procedures.
- Educator: Identifies, implements, and/or evaluates opportunities for patient/family education.
- Infection Control: Demonstrates infection control practices congruent with policies and procedures.
- Performance Improvement: Performs, participates, implements and evaluates performance improvement activities at the department level.
- Financial Accountability: Identifies opportunities for waste reduction and department efficiency.
- Information Management: Demonstrates adherence to information management polices and procedures, maintaining confidentiality at all times.
- Communication: Works as a team member through interaction, assistance and demonstration of appropriate communication skills and reporting/activation of the chain of command appropriately.
- Practices Professionalism: Performs, participates, implements and evaluates personal performance.
- Ethics/Compliance: Performs all duties ethically, complying with all policies and procedures, federal, state, and local laws.
- Environment of care: Demonstrates accountability in role and responsibilities of the 7 Environment of Care plans.
- Job Specific: Clinical Case Manager RN
REQUIRED LICENSURE/CERTIFICATIONS: Current RN or LVN licensure; Preferred: BSN level of education. REQUIRED EDUCATION/EXPERIENCE:
(Required) Registered Nurse or Licensed Vocational Nurse with clinically focused work history. PREFERRED EDUCATION, LICENSURE, CERTIFICATION, EXPERIENCE, SKILLS, KNOWLEDGE AND ABILITIES:
Prefer three-five years clinical experience within an acute health care setting with recent work history in acute care case management role or related health care experience. Working knowledge of case management philosophy/process/role, needs assessment, principles of utilization review/quality assurance, use of InterQual® or otherclinical decision support criteria, discharge planning, and reimbursement structures (i.e. Government and non-governmental payers).
Ability to read, analyze and comprehend complex clinical and financial data and its application to level of care criteria and discharge options; strong, broad-based clinical knowledge and understanding of pathology/physiology of disease processes; excellent critical thinking skills; assertive personality traits to facilitate ongoing physician communication; organize, prioritize and manage time efficiently. Computer literacy and familiarity with the operation of basic office equipment. Must be able to communicate effectively with a wide range of hospital personnel, physicians, patients/family members within various socioeconomic groups and representatives of varied outside agencies. Ability to communicate effectively with and know the age-specific needs of patients of adolescent, adult and geriatric age.
- Demonstrate an understanding of HCA's "Patients First" safety initiative through strictcompliance to all safety protocols and procedures.
- Recognizes that variables such as age, race, nationality, culture, disease-causing vulnerabilities, socio-economic factors affect the patient populations under their care. Uses interventions appropriate to these factors (e.g. interpreter, dietary preferences, social service consult, etc)
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom