Job Title: RN/LVN Case Manager - Case Management
- Performs a wide variety of tasks and functions including utilization review, discharge planning, and care coordination to assure the delivery of necessary services, efficient patient progression, and payment for the services provided.
- Serves as a liaison between the designated Avanti Hospital and payers to ensure financial coverage for the patients on a concurrent basis and documents supporting activities.
- Collaborates to coordinate resources and services for the patient/family in response to individual needs and fiscal responsibilities.
- Works with the clinical multidisciplinary team to ensure coordination of patient care and wise utilization of resources to include appropriate level of care based on InterQual criteria, and communication with the health plans.
- Documents case management activities in the patient record and in the required information system i.e. in Paragon UR Program, CERME, Nursing Progress Notes.
- Works varying shifts including regular evenings and weekends.
Essential Job Duties:
- Applies appropriate clinical knowledge in order to identify patient needs and effectively communicate medical necessity and treatment plan to payers.
- Concurrently and retrospectively reviews all inpatients and observation patients based on the Paragon UR work queue, the Avanti census and electronic health plan reports for appropriateness of admission, level of care, and length of stay utilizing InterQual criteria and documents in Paragon UR Program.
- Attends rounds with the Physician Advisor, nursing and other members of the Case Management team to discuss the gaps in patient care, respond to the patients' needs, identify the plan of care and advise of potential discharge needs.
- Reviews and works incoming denials received via fax or through correspondence (in-house patients). If the patients are discharged, scan, document and forward the denial letters to the Central Business Office (CBO).
- May assist with ED Admissions to determine the appropriate level of care and discuss with ED and Admitting physicians and health plans.
- Submits daily clinicals and confirms the payor receipt and authorization status during the patient's hospital stay, per the plan contract (but no less frequently than every 3 days).
- Educates and collaborates with the multidisciplinary team including physicians, nurses, social workers, physical therapy, dietary etc. and patients/families regarding utilization issues and medical necessity to provide choices for discharge options and community resources post-acute care stay.
- Documents options and discharge plans in CERME, Paragon UR, eRecord and other Avanti Systems.
- Estimates the expected length of stay (ELOS) based on the knowledge of the patient's condition and barriers to discharge and interactions with the interdisciplinary team. Communicates expected discharges to the unit charge nurse, patient unit and family.
- Identifies patients at risk for extended lengths of stay, readmission, and complex discharge needs, documents in Progress Notes and Paragon UR, completes Complex Case Log and submits to CM Director, Administration and the CBO.
- Identifies and documents Avoidable Days using evidence based data to address opportunities for improvement.
- Prevents denials and disputes by communicating with payers daily and documenting relevant information in Paragon UR.
- Reviews and works incoming denials or denied days received during follow up calls, fax or correspondence (in-house patients). If patients are discharged, scans, documents and forward letters to the CBO.
- Works Claims Retention Criteria (CRC) Report to ensure that edits are cleared for timely billing.
- Completes Medicare Outpatient Observation Notice (MOON) letters and gives and explains the Important Message from Medicare (IMM) letters 48 hours before discharge to the patient and/or family members.
- Provides/submits payor notifications of discharge, transfer or death and confirm all days have been authorized. If any days are not authorized, notify the Director stating why and start the first level appeal process.
- Transmits care summary to next level of care if other than home.
- Behavioral Standards:
- Exhibits customer and service oriented behaviors in every day work interactions.
- Demonstrates a courteous and respectful attitude to internal workforce and external customers.
- Must be able to develop an organized work plan in a high-volume environment with rapidly changing priorities.
- Must be able to effectively communicate with, and promote cooperation and collaboration among patients/families, physicians, nurses, community resources and social workers.
- Utilize critical thinking skills and clinical knowledge to create a viable and effective patient transition plan while identifying delays in service or quality issues that impede the progression of care required.
- Serves as a role model for the Mission, Vision and Values of the organization and fulfills other job duties as requested.
- Time management and priority setting skills.
- Must have the ability to manage multiple complex activities with tight deadlines.
- Ability to design, develop, and implement programs and care coordination with initiative and creativity.
- Skilled in working with a wide range of personalities and utilizes sound judgment in working with all members of the team, patients/families, and payer representatives.
- Able to listen, understand, problem-solve, and carry-out duties to ensure the optimal patient care outcomes.
- Professional dress and demeanor.
- Able to remain poised under stress.
- Able to use IT systems in an accurate and proficient manner.
- Contributes toward effective, positive working relationships with internal and external colleagues.
- Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization.
- Bachelor's degree in Nursing preferred, Master prepared a plus.
- Minimum of 2-3 years in Case Management Acute Care setting.
- Knowledge of healthcare reimbursement systems: HMO, PPO, capitated agreements, and PPS.
- Advanced knowledge of post- acute healthcare resources such as SNF, Home Health and Hospice.
- Strong clinical assessment skills necessary to provide utilization review and transition planning services to meet the patients' complex medical, emotional and social needs.
- Current RN or LVN licensed in good standing by the California Board of Nursing Current BLS for Health Care Provider card.
- Accredited Case Manager (ACM) or Certified Case Manager (CCM) a plus.
- To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant in order to be considered.
- Required to stand; walk; sit; use hands to fingers, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl; talk and hear; and may taste and smell. The employee is regularly required to lift, push and/or pull weights in excess of 10 pounds, with assistance. Visual abilities, auditory abilities, must be intact to perform duties.