Case Management Nurse .75 FTE

PRIMARY FUNCTIONS

Case management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for options and services to meet an individual’s and family’s comprehensive health needs through communication and available resources to promote quality cost-effective outcomes. 

ESSENTIAL DUTIES AND RESPONSIBILITIES

Utilization Management

Monitors and facilitates appropriate utilization of resources.

• Collaborates with the physician and health care team for resolution on level of care concerns.

• Advocates for both the patient at the service-delivery and benefits-administration levels and the payer to facilitate positive outcomes for the patient, the health care team, and the organization.

• Oversee utilization and training of InterQual guidelines. 

• Documents if admission criteria and severity/intensity were met. 

• Tracks and reports trends and variances in patient care, system standards, and inappropriate resource utilization.  Collaborates with the provider and health care team on documentation of variances. 

• Maintain accurate records of all communications and interventions. 

Identifies and performs insurance reporting requirements including notifications, pre-authorizations, discharge notifications, and clinical updates. 

• Performs notifications, pre-authorizations, and clinical updates within prescribed time frames and documents appropriately. 

• Facilitates response to insurance denials, disputes, and audits. 

• Implements notifications (Important Message from Medicare about Your Rights, Hospital Issued Notification of Non-coverage, etc.) in accordance with compliance standards. 

Serves as a liaison to outside agencies to coordinate and facilitate a timely review of direct skilled nursing placement requests. 

• Collects and analyzes pertinent data to evaluate patient. 

• Coordinates an interdisciplinary review to assure patient needs can be safely met. 

• Serves as point of contact for outside agency to coordinate a smooth transition for patients, families, and staff. 

Case Management

Participates in the assessment of needs and development of a comprehensive, individualized plan of care and discharge plan in collaboration with patient, family or caregiver, and interdisciplinary health care team. 

• Assessments are complete and accurate with evidence of use of relevant, comprehensive data from many sources. 

• Educates the patient, the family or caregiver, and members of the health care team about case management, resource utilization, and insurance benefits so that timely and informed decisions can be made. 

• Validates that plan of care is consistent with evidence-based practice guidelines. 

Implements and evaluates the case management plan.

• Provides services as appropriate to meet identified needs on site and in assigned clients’ homes.

• Collaborates and consults with primary provider and other resources to meet needs post-discharge as appropriate. 

• Evaluates the effectiveness of the case management plan as it relates to identified goals, objectives, and expected outcomes.   Revises plan as needed. 

• Communicates the individual plan of care to all interdisciplinary team members as changes occur and updates the communication board during normal scheduled days.              

Evidence-Based Practice

Maintains familiarization with current literature and understanding of regulations pertaining to case management and utilization management. 

• Summarizes and disseminates regulations and related information to Utilization Review Committee, providers, and other health care team members as appropriate. 

• Incorporates meaningful research findings into practice as appropriate. 

• Ensures departmental policies and procedures are based on evidence and meet regulatory and accreditation standards. 

• Serves as the chair of the Utilization Review Committee to develop and implement the organization’s utilization review plan. 

Identifies, monitors, evaluates, and takes appropriate action on quality indicators reflecting services provided and compliance with organizational initiatives and accreditation requirements.

• Systematically collects, analyzes and interprets relevant data to identify significant issues, problems, or trends. 

• Determines expected outcomes based on data analysis. 

Professional Practice

Evaluates one’s own nursing practice in relation to professional practice standards and guidelines, relevant statutes, rule, and regulations.  Supports the nursing profession by contributing to the professional development of peers and colleagues and actively participating in teams and committees.

• Takes responsibility to respond to patient care and departmental concerns through contacting appropriate resources and initiating actions for concerns identified.

• Addresses issues or concerns with colleagues directly in a constructive manner with intervention from management as appropriate.

• Shares knowledge and skills with peers and colleagues.

• Maintains compassionate and caring relationships with peers and colleagues contributing to a supportive and healthy work environment.