Clinical Case Mgr

Job Responsibilities

• Analyze patient records and assume responsibility and accountability for admission and concurrent reviews assuring the prevention of denials from all payers. Assist with notification, submitting clinical information, and coordinates with payors for approval of services within timeframes indicated by each payor.
• Compare hospital medical records to established care guidelines and communicates with various members of the multidisciplinary treatment team re expected length of stay, variances, readiness for discharge or transfer to the next appropriate level of care, and optimal recovery course/benchmarks.
• Support utilization review in monitoring, reporting and documenting on appeals at all levels, peer to peer reviews and reconsideration, and utilization review metrics.
• Communicate with attending and ED physician regarding bed status and level of care criteria. Refer questionable cases to a Physician Advisor for review, following up with attending as indicated.
• Coordinate delivery of regulatory documents and may communicate with a discharge planner as needed regarding any changes in bed status.
• Research clinical records, appropriate insurance and governmental regulations, accrediting agency standards, and history of the claim to determine next step.
• Ensure collaborative planning processes are maximized and informed decisions are made from a person-centered, strengths-based approach; in conjunction with the patient, family and healthcare team, assess and evaluate medical, rehabilitative, psychosocial and physical needs of observation and inpatient admission to ensure appropriate discharge plan are implemented.
• Reassess and reevaluate the appropriateness for the plan of care, evaluate progress towards goals, and ensure that the plan is implemented in a timely fashion. Informs team members of current patient status and post discharge care planning process.
• Review plan of care and expectations with the patient, family, physician, and healthcare team members. Assist patients in problem solving potential challenges related to the health care system, financial or social barriers.
• Discuss all aspects of care planning with sensitivity and cultural awareness.
• Coordinate with all agencies involved in the patient's pre-hospital care as well as those planning for post hospital care, including but not limited to: home health, skilled facilities, LTACH's, and DME companies.
• Provide necessary data to make a referral, provide pertinent information to facilitate transitions of care, schedule post discharge PCP appointments, and follow up with high risk patients post discharge to ensure plan occurred as expected, intervening when required.
• Serve as a contact, advocate, and informational resource for patient and their family. Acts as a patient and or family advocate by assisting the patient in achieving autonomy and self determination to reach their goals. This includes education on advance directives, patient rights and responsibilities, and regulatory notices, such as the IMM and MOON.
• Help patients express their views and choices by eliciting preferences and priorities from the patient and family regarding the discharge.
• Other duties as assigned.

Education Requirements

• Minimum: Associate Degree in Nursing (ASN) or BA/BS in Social Work
• Preferred: BSN or MSW in Social Work

Experience Requirements

• Minimum: Two (2) years' experience in utilization review and/or discharge planning.
• Preferred: Five (5) years' experience in utilization review and discharge planning.

License/Certification Requirements

• Minimum: Registered Nurse, Licensed Social Worker, Clinical Social Worker, or LMSW as appropriate based on educational preparation.