Job Description

Purpose of Position
The Case Manager is responsible for the timely facilitation and coordination of patient care for specific patient population or area of assignment. The job responsibilities include working effectively with the interdisciplinary team so as to plan and implement an individualized program of care that promotes high quality, efficient and cost effective care. The Case Manager must assess patient needs utilizing established standards/Care Maps and other approved clinical guidelines. Through ongoing communication and coordination with third party representatives the Case Manager will facilitate care that will meet established patient care needs while optimizing reimbursement.

Description

1. Screen new admissions daily for discharge planning needs. Establish priority of visits based on screening criteria. Verify accuracy of demographics and payer information in and notify admissions of corrections.
2. Patients with identified needs for follow-up are seen within one (1) business day of identification and the Initial Assessment is completed in InterQual®. Reassessments are done every three (3) days as needed for changes in medical status, diagnosis, or caregiver.
3. Review appropriateness of patient's admission and level of care needs (Inpatient and Observation) utilizing InterQual® Criteria. Follow policy and procedure if Level of Care is not met.
4. Initiates timely HINN Notices and letters of reinstatement. Coordinates patient appeal rights under the Discharge Appeals program.
5. Identifies patients and families who have high-risk complex psychosocial/financial and legal needs and refers patients to appropriate resources.
6. Responsible for utilization review on assigned unit. Facilitates third party reimbursement by responding to third party payer requests for concurrent clinical information in support of ongoing services, turnaround time by day end.
7. Works closely with attending physician/interdisciplinary team to facilitate appropriate care and services. Ensures that the interdisciplinary care plan and the discharge plan are consistent with the patient's required needs and covered services.
8. Participate/facilitate in unit's daily rounds.
9. Advocates for patients through the development of effective partnerships with patient families, payers and healthcare team. Acts as patient advocate communicating with patients/families regarding adverse determinations and other issues related to insurance coverage and ongoing care requirements. Facilitates and maintains patient's independence in decision making when appropriate.
10. Coordinate and communicate thorough and complete referral information to enhance a safe transfer of patient to other facilities or agencies. Complete all necessary paperwork based on need and regulation.
11. Demonstrates knowledge of community resources and acts as resource to staff in providing safe and effective post hospital care.
12. Participates and accurately applies approved standards of care/Care Maps and clinical pathways in evaluating and monitoring the patient's clinical course. Participates in the development and revision of pathways. Participates in care conferences on patients across the continuum.
13. Evaluates continued length of stay of patients for appropriateness per recognized InterQual® criteria. Makes appropriate referrals to Physician Advisor if criteria is not met and resolution with the attending physician cannot be accomplished.
14. Identifies days at risk for denial and initiate strategies to facilitate care and accomplish discharge.
15. Assists medical coders by obtaining necessary diagnostic and procedural information to assure appropriate reimbursement.
16. Maintains established departmental policies and procedures, objectives, quality assurance program, safety, environmental and Infection Control standards.
17. Maintains core/clinical competency and current knowledge of regulatory and payer requirements to perform job responsibilities.
18. Participates in education programs, in-services, and meetings as required.
19. Recognizes/understands responsibility of this key role and the responsibility this position demands in direct support of high quality patient care delivery regardless of assignment. This will be measured by the accountability/initiative taken in the performance of daily duties and assignments as itemized in major accountabilities section of job description.
20. Ability to work independently.
21. Complies with policies regarding dress code.
22. Performs other related duties as assigned or requested. Displays flexibility, cooperation and characteristics of a team member.

Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Hospital's commitment to CARES: compassion, accountability, respect, excellence and service.

Qualifications

• Ability to read, write and communicate in English;

• Current registration as a Registered Nurse in the Commonwealth of Massachusetts;
• Bachelor of Science Degree in Nursing preferred, (external applicants);
• Certificate in Case Management or CPUM or specialty preferred;
• Demonstrates competency with a minimum of 3 years acute care experience within the past 5 years with broad clinical experience in a hospital setting or case management .
• Demonstrate recent knowledge/experience within past 4 years in Discharge Planning and Utilization review;
• Working knowledge of InterQual®, or equivalent system.
• Strong interpersonal and negotiation skills demonstrated by a positive attitude, pleasant, professional and cooperative demeanor, with patients, physicians, fellow employees, and insurance companies;
• Excellent organization and time management skills;
• Ability to work independently and effectively in a fast pace environment;
• Ability to work productively in a stressful environment and effectively handle multiple projects and changing priorities;
• Proficient computer skills with ability to utilize and integrate updated software systems into practice.

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