Position Summary: The RN Case Manager is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity and to assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including:
- Utilization Management supporting medical necessity and denial prevention
- Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
- Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
- Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
- Education provided to physicians, patients, families and caregivers
The individual’s responsibilities include the following activities: a) accurate medical necessity screening and submission for Physician Advisor review, b) care coordination, c)transition planning assessment and reassessment, d) implementation or oversight of implementation of the transition plan, e) leading and facilitating multi-disciplinary patient care conferences, f)managing concurrent disputes, g) making appropriate referrals to other departments, h ) identifying and referring complex patients to Social Work Services, i) communicating with patients and families about the plan of care, j) collaborating with physicians, office staff and ancillary departments, k)leading and facilitating Complex Case Review, l)assuring patient education is completed to support post-acute needs , m) timely complete and concise documentation in Case Management system, n ) maintenance of accurate patient demographic and insurance information, o) identification and documentation of potentially avoidable days, p) identification and reporting over and underutilization, q) and other duties as assigned.
ü Required qualifications include an active FL Registered Nurse license with at least two years acute hospital patient care experience. BSN preferred. Accredited Case Manager (ACM) preferred. Acute hospital case management experience preferred. Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast paced environment, critical thinking and problem solving skills and computer literacy.
ü Individual works in a fast paced clinical and office environment.
PRIMARY INFORMATION, TOOLS AND SYSTEMS USED
· Patient data – hospital admission, discharge, transfer system
· Healthcare staff documentation related to patient care
· Regulatory and payor requirements
· Allscripts ® Care Management System
· McKesson Care Enhance Review Manager (CERMe) InterQual system
· Clinical data interface and secure faxing
· Patient Medical Record including Cerner and HPF
· Hospital specific Clinical Software
While performing the duties of this job, the employee is regularly required to sit, talk, and hear. The employee is frequently required to use fine motor skill (typing/data entry), and reach with hands and arms.
The employee is frequently required to stand; walk; and occasionally stoop, kneel, or crawl. The employee must regularly lift and /or move up to 20 pounds and occasionally lift and/or move up to 50 pounds.
TRAINING REQUIREMENTSMust complete Tenet’s InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Attendance at hospital and department orientation is required. Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual®, Transition Management, Utilization Management, and other topics specific to case management.
Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.