Overview The Care Manager provides a link between provider and payer organizations, physicians and the community in the transition of patient care through the health care system. Monitors all admissions for the appropriateness of observation services or inpatient hospitalization, according to InterQual criteria. Utilizes the nursing process, identifies patients with discharge planning needs and coordinates necessary services in the home or nursing facility setting. Coordinates patient care by using independent nursing judgment and works collaboratively with the interdisciplinary team. Communicates the patient’s clinical condition and care needs as appropriate. Demonstrates knowledge of the principles of growth and development over the life span and provides age‑appropriate care to the patient population served. Professional knowledge and judgment will be utilized when guidelines are unavailable or inappropriate for a given situation. Promotes the profession of nursing and professional practice through collegial support and interactions. Is primarily assigned to one hospital, but will be required to provide coverage at the other hospital as needed. Reports to the Manager of Care Management.
Education, Certification, Experience and Other Requirements are listed below.
Education / Certification Graduate of an accredited school of Nursing
Baccalaureate degree in an applicable field required
Must have a current license as a Registered Nurse in the State of Connecticut
Professional certification in case management or clinical specialty is preferred
Experience Must have at least five (5) years of nursing experience in a medical surgical acute care setting
Additional experience in case management, home care, and utilization review/management is preferred
Competencies Requires good analytical, organizational and interpersonal skills as well as the ability to communicate effectively in English, both verbally and in writing
Basic proficiency in personal computers
Essential Duties and Responsibilities Assures and facilitates appropriate and efficient utilization of hospital services. Uses InterQual criteria to determine whether the patient meets observation or inpatient care criteria and takes appropriate action when variances are identified.
Works with the Physician Advisor to ensure appropriateness of care, cost-effectiveness and best patient outcomes. Identifies problems with the care delivery system that impact LOS, quality and continuity of care, and participates in process improvement.
Provides clinical information to managed care companies in a timely manner, including severity of illness and intensity of service data to receive authorization for payment. Prevents denials through pro-active intervention with managed care reviewers, physicians and hospital staff. Administers notice of non-coverage to Medicare patients who do not meet inpatient criteria.
Submits Avoidable Days and Denial Determination forms within one week of discharge or receipt of a notice of denial. Successfully appeals denials, when indicated.
Performs comprehensive assessments and re-assessments of the patient’s condition and discharge planning needs including psychosocial, physical, educational and cultural aspects. Works with the clinical team to develop and modify the care plan to meet the needs of the patient.
Collaborates with other disciplines in patient evaluation and treatment and initiates referrals appropriately.
Initiates discharge planning in a timely fashion, develops and revises individualized discharge plans as indicated by assessment and patient response to treatment. Evaluates overall plan daily for effectiveness. Involves the patient and family in the formulation of goals.
Demonstrates understanding of level of care criteria and reimbursement factors for home care, rehabilitation, residential treatment and long‑term care in development of discharge plans. Seeks alternatives to facilitate discharge planning.
Educates patients and family, as appropriate, regarding discharge options and reimbursement and includes them in development of the discharge plan.
Documents a thorough assessment of continuing care activities in a timely manner, utilizing the appropriate format.
Provides in a legible format adequate verbal and written information necessary for continuation of care in a post‑hospital setting (W‑10, MI/MR, etc.). Content reflects an understanding of the treatment goals in the next level of care.
Facilitates timely delivery of care for Observation patients in caseload. Completes Observation Worksheet and submits within one business day.
Demonstrates flexibility, organization and ability to function under stressful situations. Utilizes critical thinking and sound judgment in priority setting and delegation.
Practices autonomously, consistent with evidence‑based standards. Pursues personal and professional growth and development. Serves as a professional role model and mentor. Provides consultation and educates hospital staff regarding LOS and continuing care resources.