Description

Job Summary:

The Case Manager is a self-directed individual whose primary function is that of the expert practitioner and who functions in the role of a case manager and intake coordinator.  Responsible and accountable for the coordination of care and reimbursement for an assigned patient population from entry into the hospital through discharge, promotes effective utilization and monitors health care resources to meet legal, regulatory, ethical, quality guidelines, development and application of patient care standards and research to enhance the quality of care to the patient and family populations (adult and geriatric).  Manages complex patient care, ensuring cost effective nursing practice, and demonstrating effective decision making for matching demands and resources to resolve clinical, professional and system issues.

Accountability will be measured by performance standards, goal achievement (personal and organizational), quality improvement activities, and patient admission growth (acute and subacute) and will be summarized in performance evaluation and counseling.

Assumes a leadership role within the interdisciplinary team to achieve optimal clinical outcomes. Arranges and facilitates post hospital services as necessary while the patient(s) progresses through the episode of care.

Responsible for all activities related to referral and acceptance process of patients into Skilled Nursing Care and Post-Acute (Swing Bed) Program.

Formulates an individualized Plan of Nursing Care for Post-Acute patients.

Responsible for developing and communicating a Discharge Plan of Care for Acute and Post-Acute Patients to members of the healthcare team, patients and their caregivers.

Demonstrates population-specific competencies (e.g. age-specific, cultural sensitivity, patient-centered communication) in performance of role.

The provision of nursing care will be provided in an environment that embraces maximum participation by the staff nurses, the ANA Code of Ethics for Nurses and the ANA Practice Standards.

Provides backup MDS support.

Job Specific Major Areas of Responsibility:

*Concurrently assess each patient, within designated patient caseload, accurately for medical necessity and the appropriateness of level of care, for resource consumption of diagnostic testing and clinical procedures, for quality and clinical risk issues, and for the completeness of physician documentation in the medical record.  Expedites decision-making accordingly if any of these parameters do not meet current policies and standards of care. (25%)

1. Medical necessity – applies approved utilization acuity criteria to monitor appropriateness of admission and continued stays and documents findings in the approved format in medical record and communicates the same to the clinical staff and patient and family. Requires detailed knowledge of payor requirements. (i.e., Medicare, Medicaid, Managed Care Contracts and Insurance companies).
2. Level of Care determination – communicates with the appropriate parties to facilitate covered day reimbursement certification for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and resolves issues with payers as needed. Facilitates getting the patient into the appropriate level of care through transfer and discharge planning.
3. Provides accurate evaluations and effective interventions to address and improve clinical and financial risk – proactively identifies and resolves delays and obstacles to discharge and seeks guidance from appropriate disciplines and departments as needed to expedite care and facilitate discharge. Addresses and resolves system issues impeding diagnostic or treatment progress.
4. Identifies potential patients for admission to post-acute services (Swing Bed Program). Collaborates with members of the healthcare team, patients, and families and significant others to coordinate a seamless admission.
5. Secures authorization from third-party payers to assure that patients referred to Swing Bed services will be have their admission covered by patients’ insurance carrier.
6. Communicates with third party payers as appropriate when there is a need to extend the length of admission to Swing Bed Services to secure authorization for the recommended additional time.

*With regards to the patients, ensures that medically-related social services are provided to assist patients in maintaining or improving their ability to manage their everyday physical, mental, and psychosocial needs. (25%)

1. Makes arrangements for obtaining needed adaptive equipment, clothing, and personal items.
2. Maintains contact with the family and designated significant other (with the patient’s permission) to report on changes in health, current goals, discharge planning, and encouragement to participate in care planning.  Assists staff to inform the patient, and those they designate, about the patient’s health status and health care choices
3. Makes referrals and obtains services from outside entities as needed in the physical and/or emotional care of the patient.
4. Assists patients with financial and legal matters by obtaining appropriate support to address concerns.
5. Develops and implements discharge planning service to assure smooth transition back into the community.
6. Facilitates access to any counseling services that patients may require.
7. Assists patients to determine how they would like to make decisions about their health care and whether or not they would like anyone else to be involved in those decisions.
8. Ensures that the needs of a grieving patient are met.
9. Coordinates the care and services of patients who may require dental and denture care, podiatric care, eye care, hearing services, and obtaining equipment for mobility or assistive eating devices.
10. Evaluates and identifies supporting evidence that social services interventions successfully address the patients’ individual needs.

*Collaborates continually with patients, families, medical staff, caregivers, administrators, all other departments, community, and third-party payors to problem solve and pace care. (20%)

1. Works with physician and all members of multidisciplinary team to facilitate care for designated caseload, monitors patient’s progress, intervening as necessary and appropriately to ensure that the plan of care and services provided are patient focused, high quality, efficient and cost effective.
2. Actively participates in and/or initiates (as needed) effective care coordination rounds, family meetings, team meetings, and other collaborative events. Informs and respects patient and family choice.
3. Develops primary and alternative discharge plans and implements appropriately using all available information, creativity, and assistance.  Meets directly with patient and family to assess needs and develop plan. Communicates with multidisciplinary team in all phases of the discharge planning process from initial assessment, planning, interdisciplinary collaboration, teaching, transportation needs, etc.

*Promotes safety, best clinical and case management practices, and quality care through example, team leadership, and participates in varied performance, clinical, and process improvement activities. (10%)

1. Sets an example as stated above.
2. Meets individual quality, satisfaction, and financial Length of Stay (LOS) targets set annually by Piedmont McDuffie.
3. Participates in direct patient care as needed and appropriate to level of training and/or licensure.
4. Performs other duties as needed or assigned by supervisor.

*Demonstrates knowledge of functional health patterns, physiology, pathology, psycho-sociology and clinical technology in the diagnoses, treatment and evaluation of patients in acute and post-acute clinical settings.  Demonstrates clinical competence in problem-solving skills based on nursing process knowledge, clinical experience and sound judgement. (10%)

1. Assesses individual patient care needs through rounds, discharge planning efforts, patient and family conferences, care planning meetings and referrals from various health team members.
2. Assists team members with decision making in clinical situations.
3. Plans with team members to identify priorities and realistic outcomes from interventions.

*Assists with Development and revision of standards, policies, Patient Care Practice Standards (PCPS) as requested. (2%)

1. Contributes to the development of standards, policies, PCPS regarding Case Management activities.

*Applies principles of adult learning theory in the education of nurses, nursing students, and other healthcare providers. (2%)

1. Plans formal and informal educational opportunities for team members regarding Case Management related topics; as well as for patients and/or families based on patient/family continuum of care needs.

*Incorporates coaching and skillful guidance to support the medical staff and nursing through orientation, training, and continuous staff development regarding Case Management related topics. (2%)

1. Serves as a resource person for all team members, physicians, other departments related to the role of Case Management.
2. Provides consultation to nursing, therapy and medical staff regarding appropriate patients who may be eligible for admission to Swing Bed Services.

*Participates with appropriate staff in the development, implementation and evaluation of unit and hospital strategic planning and goals. (2%)

1. Keeps Nursing Leadership informed of activities that occurred in their absence and seeks assistance from appropriate resources (e.g., CNO, DON, Nurse Manager, etc.) when needed.
2. Collaborates with leadership on marketing activities through design of brochures, program flyers and poster presentations, and bulletins as assigned.
3. Assists, identifies and implements cost-effective practices, direct generation of revenue, and budget management activities.
4. Contributes to the financial integrity of the department through the identification and implementation of cost-effective practices, direct generation of revenue, and budget management activities.

*Participates in hospital committees, meetings and task force groups as appointed. Embraces shared governance by serving on councils as participant or leader to achieve identified outcome, goals and objectives of nursing. (2%)

1. Demonstrates 80% meeting attendance and 100% information sharing. Fulfills the duties and responsibilities identified in the appropriate shared governance council document.
2. Functions as an effective group and team leader or member based on an in-depth understanding of team dynamics and group processes.
3. Performs other duties as needed and assigned by supervisor.