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Summary

RN Case Managers provide a systematic collaborative approach to provide and coordinate healthcare services to a defined population. The framework includes five components: assessment, planning, implementation, evaluation, and interaction. RN Case Managers actively participate with their clients to identify and facilitate options and services for meeting the individual’s health needs, with the goal of decreasing fragmentation and duplication of care and enhancing quality, cost-effective clinical outcomes. The RN Case Manager works closely with, and delegates care to, the High-Risk Social Worker/Behavioral Health Clinician because of assessment and determination of social needs.

Essential Duties and Responsibilities

+ Supports and promotes the mission and values of Covenant Health Ministry.

+ Responsible for performing timely assessments of outpatients, observation patients and inpatients patients (as applicable dependent on the location of services being reviewed) based on policies, procedures and criteria as established by the hospital and the department.

+ May communicate with payor representatives regarding patients’ level of care and regarding plans for discharge.

+ Responsible for communicating and collaborating with internal departments (such as, patient registration, patient accounts and others), as appropriate, to verify payer source as soon as possible upon the decision that the patient is to receive services.

+ Delegates cases to High-Risk Social Worker/Behavioral Health Clinician based on assessment including social determinants of health.

+ Acts as the lead in assigned area in management of patients discharge planning working closely with the High-Risk Social Worker/Behavioral Health Clinician

+ Perform ongoing evaluation and critical analysis of the patient’s progress to ensure that the patient’s Hospital needs are being delivered in the most appropriate setting and in a timely manner.

+ Collaborate with the interdisciplinary team to evaluate objectively and critically all information related to the current or proposed treatment plan to identify potential barriers, clarify, or determine realistic goals and objectives, and seek appropriate alternatives for the patient.

+ Serves as a patient advocate to ensure quality outcomes. Refers all cases with potential quality concerns as per policy including entering cases into applicable software applications.

+ Identifies and facilitates patient/ family conferences as needed.

+ Respects the dignity and confidentiality of the patient in all verbal/written information and communication.

+ Supports the role of the clinical primary nurse and utilizes their clinical expertise and input in the care of the patient.

+ Seeks peer assistance and/or provides consultation regarding complex cases and/or cases that have deviated from the initial plan of care.

+ Represent the patient’s interests by advocating necessary funding by providing clear and timely reviews to the payors, appropriate treatment alternatives, timely coordination of health services, and frequent re-evaluation of progress and goals.

+ Facilitates completion of advance directives

+ Works collaboratively with the Hospitalist group and UR nurses to determine level of status based on medical necessity

+ Responsible for collaborating with physicians, the UR staff to identify patient stays that lack medical necessity (whether based on initial or continuing stay review) to determine whether a level of care change order or a non-coverage notice must be provided.

+ Collaborates with patient accounts and others to provide the patient or legal representative with appropriate and timely notice of non-covered services, in accordance with hospital and department policies and payor guidelines.

+ Plans, communicates and collaborates with the patient and/or family, the physician and the interdisciplinary team to develop the optimum post-hospitalization care plan utilizing the available resources to promote a quality, cost-effective and timely discharge.

+ Initiates referrals to non-acute facilities, home care providers and all post-hospitalization services in a timely manner to assure continuity of care and prevent delays in discharge.

+ Manages length of stay (LOS) by proactively collaborating with the Hospitalist group, patients, and caregivers to develop a safe, effective discharge plan.

+ Communicates clearly and accurately to the post-hospitalization providers of care and service, about the patient’s clinical status and discharge needs.

+ Provides updates to the physician, patient and/or family with any changes to the original discharge plan of care while ensuring the plan is safe, appropriate, acceptable, and feasible.

+ Applies relevant CMS regulations and discharge guidelines to ensure compliance with Medicare Conditions

+ Educates patients and families on the concept, process, and goals of case management.

+ Educates patient and families on the treatment plan and interventions throughout the hospital course in collaboration with the interdisciplinary team.

+ Facilitates education of the interdisciplinary team related to the individual patient case management goals, InterQual criteria and coverage determinations, multi-system disease processes, and payor criteria.

+ Identifies opportunities for improvement in processes and quality of care and communicates findings to the manager of the department.

+ Maintains current knowledge of DNV & CMS regulations.

+ Demonstrates a commitment to maintain competencies and participates in those activities, which contribute to the ongoing development of self, the profession, and other members of the health care team.

+ Mandatory in-services are attended /documented.

+ Annual goals are achieved.

+ Attends pertinent case management/utilization review programs to maintain current knowledge of UR practices.

+ Acts as a role model for other case managers.

+ Maintains current knowledge of organizations’ policies and procedures.

+ Maintains/enhances professional development/skills required to function as a Case Manager and fulfills organizational requirements (i.e., data entry, computer skills).

+ Strives to enhance own professional and personal growth.

+ Coordinates special projects at the request of the VP MA / CMO and/or Director of Care Coordination or Manager Care Coordination/Case Management

+ Other duties as consistent with this role.

For the SBHU UR

+ May communicate with payor representatives regarding patients’ level of care and regarding plans for discharge.

+ Responsible for communicating and collaborating with internal departments (such as, patient registration, patient accounts and others), as appropriate, to verify payer source as soon as possible upon the decision that the patient is to receive services.

+ Perform ongoing evaluation and critical analysis of the patient’s progress to ensure that the patient’s Hospital needs are being delivered in the most appropriate setting and in a timely manner.

+ Facilitates education of the interdisciplinary team related to the individual patient case management goals, InterQual criteria and coverage determinations, multi-system disease processes, and payor criteria.

+ Maintains current knowledge of DNV & CMS regulations.

+ Identifies cases in which a Hospital-Issued Notice of Noncoverage (HINN) or Advanced Beneficiary Notice (ABN) is warranted.

+ Documents outcome of review and communicates findings rapidly and accurately, assuring an appropriate order is obtained, when necessary.

+ Ensures payers receive complete and accurate clinical information to support assigned level of care and hospital status, as necessary, and documents as per department guidelines.

+ Follows established UM processes for patients not meeting criteria by utilizing second level review / Physician Advisor services.

+ Identifies opportunities for physician peer to peer reviews when adverse determinations are received.

+ Identifies and tracks delays in care / services, inappropriate admissions, and unnecessary continued days by utilization of avoidable day tracking in the electronic medical record.

+ Develops and maintains professional relationships with department team members and members of the medical staff.

+ Participates in assigned committees and reports out any significant changes or new information to the team.

Job Requirements

+ Registered Nurse licensed in New Hampshire required

Job Knowledge and Skills

+ Ability to multi-task

+ Ability to work under deadlines

+ Able to work independently

+ Strong organization and time management skills

+ Excellent communication skills

+ Good computer skills

+ Proven leadership and team building skills preferred

Education and Experience

+ Minimum of five years broad clinical experience preferred

+ Case management and/or Utilization Management experience is preferred

+ Certification as CCM or ACMA-RN preferred Covenant Health Mission Statement

We are a Catholic health ministry, providing healing and care for the whole person, in service to all in our communities.

Our Core Values:

Compassion

We show respect, caring and sensitivity towards all, honoring the dignity of each person, especially the poor, vulnerable and suffering.

Integrity

We promote justice and ethical behavior, and responsibly steward our human, financial and environmental resources.

Collaboration

We work in partnership, dialogue and shared purpose to create healthy communities.

Excellence

We deliver all services with the highest level of quality, while seeking creative innovation.

Applicants, employees and former employees are protected from employment discrimination based on race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age (40 or older), disability, and genetic information (including family medical history).