· Coordinates the integration of social services/case management functions into the patient care, discharge planning processes in collaboration with other hospital departments, external service organizations, agencies and healthcare facilities.
· Performs initial case management assessment to determine care coordination and discharge planning needs. Conducts admission and concurrent medical record review using specific indicators and criteria in accordance with regulatory and contractual requirements as well as internal policy. Uses established medically necessity criteria as described by policy to conduct screening for appropriate-ness of admission (IP verses observation) and continued stay for intensity of service/severity of illness. Escalates cases as appropriate and per policy to Physician Advisor and Director. Collaborates with Bed Management to ensure appropriate bed placement based on level of care. Assimilates information obtained from information systems, service schedules, registration area, Bed Management, clinics, other facilities, and insurance companies to accurately assess patient clinical needs and treatment.
· Acts as patient advocate by negotiating for, and coordinating resources with payers, agencies and vendors during inpatient and transition phases.
· Identifies and communicates quality and risk issues to the appropriate staff/departments in a timely manner.
· Acts as a resource and provides staff and physician education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.
· Reviews clinical and demographic information for accuracy and completeness and proactively interfaces with payer, where required, to ensure that hospital meets payer requirements for observation or inpatient services and in instances when insurance information/coverage seems unclear or unfamiliar. Ensures that the proper sequencing and scheduling of interventions, treatments and procedures are in accordance with the patient’s treatment plan, that care is expedited and that care delays and denials of payment are avoided.
· In collaboration with the patient/family, physicians and interdisciplinary team, the case manager ensures patient progression through the continuum in an efficient and cost-effective manner. The case manager is responsible for identifying, initiating and managing optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety and length of stay management. Independently identifies and communicates any problems or issues that affect patient flow or outcomes to the Director in appropriate timeframes. Identifies (internal or external) variances/obstacles to efficient or timely care and positive patient outcomes and intervenes with the healthcare team to overcome or eliminate these when possible. Identifies and participates in the development of strategies to reduce unnecessary LOS, resource consumption, implementing and documenting results. Mobilizes resources and interviews, as needed, to achieve expected goals and to assist in achieving desired clinical outcomes within the desired timeframe.
· Acts as a liaison between providers to optimize communication and facilitates a smooth transition through the healthcare system. Communicates effectively with physicians to obtain necessary information to complete all admission and concurrent reviews as required to prevent unnecessary delays and denials of service. Facilitates communication within the healthcare team to coordinate the patient’s treatment plan progress and ensures patient/family understanding of the treatment plan.
· Coordinates and implements the discharge plan for patients with post-care needs (i.e. home health, DME, transfers to SNF, etc.) in collaboration with the Social Worker. Identifies patients/families appropriate for referral to the Social Worker: those who would benefit from support that better enables them to deal with the impact of illness on individual family functioning and to achieve maximum benefits from healthcare services.
· Identifies and communicates relevant information to the care team related to patients frequently seen or frequently re-admitted.
· Issues Medicare Notices of Non-Coverage and assists in appealing insurance denials for assigned units. Partners and communicates with Finance department per department policy to support and ensure accurate billings, pro-active audit and denial management.
· Participates in the development of process/systems to measure/monitor clinical practice. Obtains reviews and analyzes LOS, resource utilization, outliers, readmissions denials and delayed days for assigned patients. In addition, will collect/input data or information into appropriate databases or collection tools, as indicated by Director. Utilizes thorough knowledge of various computer/ information systems to perform assigned duties.
· Documents activities, including utilization review activities, statistics, clinical assessments and plans in a thorough and timely manner or per department policy.
· Stays abreast of changing clinical trends, criteria, regulatory matters and third-party payer requirements related to clinical care, discharge planning and precertification of after-care benefits.
· Participates on committees or workgroups, as directed by Director.
· Performs other duties as assigned by the department Director.
Under general supervision of the Director and/or Manager of Case Management, in collaboration with the patient/family, social workers, physicians and interdisciplinary team, the RN Case Manager ensures patient progression through the continuum of care in an efficient and cost-effective manner. The RN case manager is responsible for identifying, initiating and managing optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety and length of stay management. Support and expertise are provided through comprehensive assessment, planning, implementation and overall evaluation of individual patient needs. Care coordination, utilization review and management, as well as discharge planning are accountabilities of this role. Education is provided to physicians and other members of the team on the issues related to utilization review including inappropriate admissions and placements. Payer-based requests regarding individual members are fulfilled, where appropriate and pertinent. The Case Manager adheres to departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all
KNOWLEDGE AND SKILLS REQUIRED:
Â· Ability to communicate effectively with diverse populations
Â· Interpersonal skills that promote teamwork
Â· Critical thinking and problem-solving skills
Â· Effective organizational skills
Â· Proficiency in the daily use of standard office equipment such as computer, phone, fax, pager, copier etc. and skill in utilizing Microsoft Word and Outlook tools
KNOWLEDGE AND SKILLS PREFERRED:
Â· Superior clinical skills to determine appropriate clinical and other information for medical necessity reviews and identify appropriate mechanism to address delays or variation for expected care practices.
Â· Significant knowledge and understanding of availability of community and post-acute resources and related payer requirements.
EDUCATION AND EXPERIENCE REQUIRED:
Â· Associates Degree in Nursing
Â· Minimum of two yearsâ™ recent acute care experience
Â· Minimum of an additional two yearsâ™ experience in healthcare related fields
EDUCATION AND EXPERIENCE PREFERRED:
Â· Masterâ™s degree in Nursing
Â· Minimum of two years of utilization review/case management experience and a minimum of one year of experience in discharge planning in an acute care setting highly desirable.
LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:
Â· Current valid State of Florida or multi state license as a Registered Nurse
LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:
Â· Case Management certification highly desirable â“ ACM (Accredited Case Manager), CCM (Certified Case Manager), RN-BC (Board Certified in Case Management)
AdventHealth Greater Orlando (formerly Florida Hospital) is one of the largest faith-based health care providers in the United States. For 150 years, we have carried on a tradition of providing whole-person care that not only addresses patients' physical ailments, but also supports their emotional and spiritual well-being. We demonstrate the same level of compassion and care for our employees as well, doing all that we can to help them realize their full potential – both personally and professionally.