The Case Manager utilizes advanced nursing skills and knowledge of resource management and fiscal responsibility to coordinate the clinical care for a designated patient population across the continuum of care. The responsibilities include but are not limited to clinical effectiveness, discharge planning, care coordination, clinical resource management and core measure documentation. The Case Manager interacts with Medical, Nursing and Ancillary staff to facilitate quality based, cost effective patient outcomes and ensure care is provided in the most appropriate setting.
Essential Duties and Responsibilities
Transition of Care Planning • Reviews and assesses selected cases within one business day of admission and as appropriate throughout the patient’s stay to assess and execute transition of care planning requirements that ensure timely and appropriate discharges.• Participates/coordinates in Care Progression Rounds and patient care conferences.• Utilizes [CM Program/Tool] according to department standards to make Discharge Planning arrangements and document interventions.• Identifies actual and potential delays in service or treatment and works with the appropriate individuals, including but not limited to, the patient, patient family, caregivers, Social Work and Denials Management to ensure timely action/resolution.• Works with multidisciplinary staff to ensure patient/family has received appropriate information and education prior to transition to the next level of care.• Identify and solve problems related to discharge needs, implement a plan of care and coordinate a safe and timely discharge.• Identify and arrange for provision of skilled home care (nursing, PT/OT, Dietitian, SW, etc.) medical equipment and supplies needed for home care services.• Coordinate the preparation; delivery and scheduling of infusions, enterals and treatments with patient’s hospital care providers and patient’s discharge time.• Collaborate with home care providers for benefits and coverage of home care services.• Advocate, mediate and negotiate to formulate a cohesive plan for maintaining or enhancing patient’s health status and moving the patient safely to the home or next level of care.• Provide ongoing consultation and training to medical staff and other health care professionals on discharge and home care issues; participate in process improvement activities; identify barriers in service delivery systems and develop a process for improvement.
Utilization Review • Reviews assigned patient population to ensure that admissions, continued stays and ancillary services are medically necessary, cost-effective and provided in the appropriate setting.• Using the [CM Program/Tool] work list, determines daily work assignment and performs concurrent chart review.• Evaluates initial level of care and patient type for all patients to ensure:o Appropriate use of facility resources.• Interacts with Resident and Attending Physicians as needed to ascertain certain clinical findings to meet the appropriate episode day criteria, length of stay and patient care guidelines and assures appropriate documentation. Escalates to Review Physicians and Physician leaders to support appropriate length of stay (LOS) and patient transitions. • Discusses admission criteria and expected date of discharge with care team
Quality/Compliance • Concurrently reviews patient medical records for admission appropriateness, protocol compliance/appropriate variance related to JCAHO/CMS core measures. • Ensures and facilitates compliance with protocols and the documentation requirements, which may include face to face communications, phone communications and discussion with physicians and clinical staff.
Professional Development• Stay abreast of payer admission criteria and expected length of stay. Attends appropriate clinical and professional organizations, workshops and meetings.• Stays abreast of community resources available to facilitate safe patient transitions of care.• Remains current on clinical advancements related to primary patient population.• Pro actively seeks to understand areas/roles outside of immediate area/role within department
Other • Demonstrate customer focused interpersonal skills, utilizing problem solving process and critical thinking.• Communicate and resolve conflict with physicians, health care team members, community agencies, clients and families with diverse opinions, values and religious/cultural ideas.• Performs other duties as assigned, including for example, participation in planning sessions for departmental activities.• Collaborates with health care team on the plan of care, referrals and ongoing needs of the patient. Facilitates communication and coordination of this plan of care with the residents/attending physicians and the health care team. Communication is concurrent and proactive. Goal is to increase quality, efficiency and patient satisfaction while managing LOS and cost for targeted population.• Works to improve quality through reduction in treatment delays, use of clinical pathways and monitoring of quality indicators. Facilitates timely tests/procedures; obtains lab results; as needed, discusses the implications for discharge with nursing staff and residents. Evaluates with the team, the patient’s response to pharmacological and therapeutic treatment regimens. Collaborates in the preparation of discharge forms/paperwork and prescriptions that often delay the discharge.• Collaborates with the health care team to identify resources available for the patient/family; provides, either directly or through referral. Coordinates the provision of education for patient and family regarding the plan of care and health care needs. Assures implementation and monitors pathways and patient care protocols. Keeps patient and family informed as appropriate.• Helps to develop, revise and evaluate tools needed to facilitate care coordination and patient care standards. Participates in process improvement and evaluation of patient outcomes for specific patient populations. Collects data on clinical resource management, LOS, readmission <30 days as well as other data on identified patient outcomes. Participates with team in quality improvement activities. Completes and submits statistical data in a timely manner.• Documents in Midas as assigned.
Licenses & certifications
Specific knowledge, skills, and abilities
and doctors who treat who give the nurses lots of autonomy and respect. I also love the patients and families we have. They are very involved in their child’s care and appreciative of what we do for them.
Kelsei, RN, BSN, CPN