Provides assessment, screening and ongoing review of the clinical course to all patients who are referred to the case manager. Identifies case management needs in collaboration with the interdisciplinary team and initiates a plan to develop, manage and evaluate integrated patient delivery systems. Collects quality and variance data as well as utilization management. Utilizes clinical experiences and expertise in conjunction with the managed care environment in collaborating on clinical interventions and addressing resource utilization issues. Demonstrates critical thinking and creative problem solving by collaborating with members of the interdisciplinary team.
As a member of the Case Management department, manages patient care through the continuum by facilitating the achievement of optimal outcomes in a cost effective manner. Negotiates, procures, monitors and coordinates services and resources needed to reach the identified goals. Continuously evaluates the effectiveness of the case management plan with the physician and rest of the healthcare team and modifies as needed. Communicates with the patient, family and healthcare team regarding progress on plan.
Patient Care Management:
Screens all patients referred to Case Manager for appropriate management and plan development.
Collaborates and participates with unit and/or specialty based clinical nurse specialist, the primary nurse and physician in the ongoing clinical assessment of patient's status and care management.
Serves as the leader of the Med/Surg/Ortho Case Management Team and directs/utilizes Resources to ensure quality outcomes for the patient by performing the following:
Confirms demographic information with patient/family.
Determines necessity of intervention and appropriate level of care.
Develops plan of care in conjunction with the healthcare team.
Provides emotional support to the patient/family during patient's illness in conjunction with the medical and nursing staff.
Utilizes appropriate resources to optimize patient outcomes; such resources include but are not limited to rehabilitation, respiratory care, dietetic, ElderCare and other clinical services.
4. Utilization Management/Managed Care
Coordinates and organizes a timely and accurate review of each medical record for severity of illness and intensity of service thus satisfying state and federal regulations encompassing:
Works with MD offices to assure Compliance with entry requirements within each payor source.
Works with Admitting to insure Appropriate setting and requirements.
Provides clinical information as necessary to obtain Authorization for acute inpatient care.
Monitors and manages the utilization of observation services at NEBH.
Verifies patient admission information for each assigned patient within 24 hours of patient's admission and determines patient's appropriateness for acute hospital level of care.
Monitors patient's clinical course to verify patient's continued need for acute hospital level of care as required for assigned patient population(s).
Provides third-party payors with concurrent review information as needed to comply with payors' requirements for documentation of medical necessity and negotiates resolution of any disagreement over the need for acute hospital level of care if and when this is appropriate.
Intervenes with the appropriate parties regarding inappropriate admissions and delays in discharge.
Responds to patient questions regarding inappropriate admissions and delays in discharge.
Intervenes with appropriate individuals/departments regarding delays in service that may have an impact on quality of patient care and/or length of stay.
5. Discharge Planning
In collaboration with the Social Worker, the Case Manager is responsible for directing and utilizing resources for discharge planning
Determines the level of care required for post discharge services and the linkage to existent community/health services.
Serves as a resource to the inter-disciplinary team for discharge planning options and assessing the financial impact.
Provides clinical information to third party payors to certify the need for post discharge services and negotiates coverage for appropriate post discharge services.
Reviews patient admission information for assigned case load and determines anticipated length of stay and discharge plan and begins discharge planning process in collaboration with the interdisciplinary team, patient and family.
Prepares documentation regarding level of care if this is necessary for discharge planning.
Interacts with home care agencies and facilities to ensure safe and timely discharge as needed.
Ensures follow-up contact with patient/family and community agency or facility to evaluate the effectiveness of the discharge plan.
Ensures coordination of the communication process with patient/family concerning the discharge plan including coordination of family meetings.
Identifies and addresses system issues and makes recommendations.
Participates in quality improvement activities designed to evaluate the appropriateness and effectiveness of the service delivery system in which case management operates.
Participates in the development or revision of hospital policies pertaining to admission, discharge and patient care processes.
Collects and analyzes variance data to identify opportunities for improvement in hospital-wide systems for the delivery of patient care re: LOS, cost, practice patterns, charges and efficiencies or lack thereof, current trends and analyze reports.
Provides data for the Utilization Review Committee.
Under the direction of the Service Line Administrator and in collaboration with the Case Management Coordinator.:
Analyzes data and make recommendations to change medical practice to enhance efficiency.
Acts as liaison between fiscal and clinical areas and provides data to maximize reimbursement.
Communicates, collaborates and maintains effective working relationships with the healthcare team regarding the appropriate utilization of acute inpatient hospital services and development and actualization of the discharge on a daily basis.
Ensures that the patient and family receive consistent information regarding anticipated length of stay, treatment plan and discharge care plan.
Maintains effective working relationships with insurance representatives as well as agencies and facilities that provide post-discharge services.
Communicates and collaborates:
To ensure that case management needs of assigned patients are met without duplication of efforts.
To ensure adequate documentation in the patient's medical records on a daily basis.
To ensure appropriate individual(s) or group(s) address systems or practice patterns identified through variance data analysis as necessary.
Internal Number: JC2910
About New England Baptist Hospital
New England Baptist Hospital (NEBH) is the premier regional provider for orthopedic surgery and the treatment of musculoskeletal diseases and disorders. NEBH has received national recognition, consistently ranked as one of America’s top hospitals for orthopedics by U.S. News and World Report. NEBH has also been nationally recognized for high patient satisfaction and leadership in quality and clinical outcomes. The hospital has ranked in the 95th percentile and received the prestigious national Press Ganey Guardian of Excellence Award for high patient satisfaction for the past ten years.
NEBH is an affiliate of Tufts University School of Medicine and conducts teaching programs in collaboration with Harvard Medical School. NEBH has been the official hospital of the Boston Celtics for over 30 years.