RN Case Manager
Evenings and 3 weekends/month
Minimum Qualifications: Current RN License in State of Texas
Experience and/or level of competency: Understanding of healthcare/HMO industry. Knowledge of financial and/or statistical analysis. Current clinical knowledge. Basic computer knowledge. Ability to read and communicate effectively in English. Additional languages preferred Strong written and verbal skills.
Responsible for the coordination and implementation of case management strategies pursuant to the Case Management Plan. Plans and coordinates care of the patient from pre-hospitalization through discharge. Works with all members of the healthcare team to assure a collaborative approach is maintained in care and treatment of the patient. Reviews care and treatment for appropriateness against screening criteria and for infection control, quality and risk assessment documenting same in computerized database. Responsible for authorization of appropriate services for continued stay and through discharge. Plans and coordinates home care services and needs.
- Provides discharge planning and at home follow-up assessment (via telephone, in some cases may make home visit).
- Coordinates the discharge planning function in conjunction with the social worker, assist Quality Management Coordinator and Risk Manager with screening, investigation and problem solving as needed.
- Assists the Utilization Management Department with all utilization activities as requested and directed.
- Participates in education on and implementation of clinical guidelines and protocols. Provides or arranges patient teaching as appropriate.
- Continues contact with patients with chronic diagnoses to assist with life style changes as needed to prevent recurrence or exacerbation of chronic illness.
- Meets with patient and family to assist with disease management planning. Works closely with DC planner to integrate psychosocial management of patient/family needs.
- Participates in performance improvement activities, frequently attending and participating in performance improvement team efforts.
- Delegate’s assignments to staff related to patient and family needs.
- Serves as a resource for department managers, staff, physicians, and administration to obtain information or clarification on accurate and ethical reporting and documentation standards, guidelines, and regulatory requirements.
- Available for assessment and evaluation of patients returning through the Emergency Department to collaborate with healthcare providers to prevent readmission as necessary.
- Effectively uses software and Clinical/Documentation Improvement (CDI) tools to conduct concurrent review to validate documentation adequacy.
- Effectively performs accurate statistical analysis and compilation of reports to facilitate data review. Demonstrates ability to query physicians for clarification and specificity of documentation in accordance with hospital policy and the AHIMA Practice Brief: Developing a Physician Query Process.
- Compares coding and reimbursement profile with national and state norms to identified variations requiring further investigation.
- Conducts trend analysis to identify patterns and variations in reporting practices and case mix index.
- Interprets data for reimbursement applications.
- Ensures the appropriate dissemination and communication of all reimbursement regulation, policy, and guideline changes to affected personnel.
- Appropriately consults the Sr. Director of Revenue Cycle or ACS consultant when indicated by review results and or query response.
- Demonstrates ability to coordinate final reporting of diagnoses with coding staff, providing clinical recommendations as needed. Maintains CDI tools used in data tracking and analysis:
- Query Log
- DRG Calculation Log
- Utilizes SBAR, to facilitate coordination of patient care and ensure accurate documentation.
- Plans patient care in collaboration with all members of the healthcare team.
- Keeps patient informed of progress and provides information related to disease progression.
- Coordinates interdisciplinary discharge planning for optimal patient care.
- Orders and arranges for home care equipment, healthcare needs.
- Works with third party payers to validate need for patient care and home care environment needs.
- Educates staff on all aspects of patient’s hospitalization and continuing care.
- Reviews patient care activities for occurrences and trends that affect the quality, cost effectiveness and delivery of services. Assures that the outcome of review is appropriately maintained in the computer database.
- Assumes responsibility for timely completion of required case management reports for presentation to the Utilization/Medical Review Committee.
- Consults other departments, entities, Home Health and SNF’s as appropriate, to collaborate in patient care and performance improvement activities. Collaborates with other departments to identify operational problems and develop solutions/resolutions.
- Functions as a patient/family advocate.
- Documentation meets current standards and policies.
- Assures patient returned from hospital to safe environment
- Maintains optimal continuum of patient care through efficient and effective planning, assessing and coordination of healthcare services.
- Performs other duties as assigned