This position has the responsibility to promote case management activities through the health continuum. Case Management starts in the pre-acute phase and continues through the healthcare continuum. Case management begins with the assessment of premorbid health status, current medical condition and post-acute needs. The Case Manager also fulfills Utilization Management responsibilities, including initial UR assessment within 24 hours of admission and concurrent continued stay reviews, ensuring that services are being delivered at the most appropriate level of care to meet the client’s needs and to secure reimbursement from payers.
Utilizing an interdisciplinary team approach, this position acts as a consultant and educator on matters referring to alternative levels of care and managed care issues. Through collaboration, case managers provide optimal patient care through, assessment, planning, implementation, and evaluation of neonatal, pediatric, adolescent, adult, and geriatric patients and families . This position also provides information such as certified LOS and reimbursement issues to physicians as needed to ensure the appropriate and timely disposition of the client to the next level of care. The Case Manager monitors and documents the progress of the plan, making revisions as needed, to assure a smooth transition to the next level of care at the time of discharge.
Specifics of Position:
• Excellent documentation and communication skills and must be able to use critical thinking, find solutions quickly and be comfortable escalating when services or care are not delivered efficiently or appropriately .
• Utilization Review, including initial UR assessment within 24 hours of admission
• Initial assessment on high and moderate risk patients within 24 hours of admission (LACE+)
• Refer patients with psychosocial barriers to discharge to SW
• Participate in IDDRs presenting GMLOS, ALOS, and discharge barriers
• Drive progression of care utilizing evidence based clinical guidelines (i.e., InterQual)
• Facilitate a discharge plan based on clinical needs and resources (e.g., wound vac)
• Attends rounds and ensures:
• All orders written
• Discharge plan is in place and in computer
• Appropriate referrals made to Social Workers
• Choice forms are obtained (when needed )
• IMMs are signed 48 hours prior to DC
• All are in agreement with discharge plan, date of discharge, and plan for care transitions
• Reviews charts and ensures when appropriate:
• All orders are written and signed and follow up with physicians
• Face to Face documentation is done
• DC summaries are written and in system in time for discharge
• All tests are scheduled timely and escalate as needed (Lab, Imaging, Surgery)
• LOS does not extend beyond calculated GMLOS and ensure everyone on care team is working towards timely discharge.
• Clinically complex cases are worked up appropriately for discharge needs (wound vac, IV meds, Meds Requiring Pre Approval, etc.)
• Incumbent must respect beliefs and values while advocating for the client’s right to self-determination and to make informed choices.
• Incumbent documents all chart and phone reviews, identifies and communicates potentially avoidable/non-reimbursed days, and quality indicators (such as re-admissions).,
• Delivers non-coverage letters as set forth by payer and/or regulatory compliance.
• This position acquires and maintains knowledge and competencies related to the expectations of their position including an extensive knowledge of post-acute admission criteria (Rehab, LTAC and SNF etc.). Practice is aligned with the mission, vision and goals of the Integrated Health System. She/he participates in Quality Improvement initiatives.
This position does not provide patient care.