Overview The Care Manager combines clinical expertise with knowledge of medical appropriateness criteria, and applies principles of utilization and quality management, discharge planning and the management of clinical/financial resources as a facilitator and consultant to the multidisciplinary patient care team. The Care Manager predicts, facilitates and evaluates the transition of patients across the care continuum and ensures linkages with post-acute discharge providers.
Essential Duties and Responsibilities These duties and responsibilities described below represent the general tasks performed on a daily basis. Any other duties as needed to drive to the vision fulfill the mission and abide by the values of the organization.
Demonstrates the knowledge base and essential psychomotor skills required to effectively carry out the job.
Demonstrates the ability to interpret, analyze, and apply relevant data to prioritize and determine a course of action appropriate to meet the patients’ management needs.
Demonstrates effective communication and collaboration with culturally and professional interpersonal skills.
Demonstrates effective time management and the initiative to carry out job responsibilities in a timely manner.
Effectively assess, plans, implements, and evaluates strategies that ensure the appropriate utilization of clinical resources and management of length of stay.
Effectively assess, plans, implements, and evaluates the effectiveness of the discharge plan for the assigned caseload of patients.
Meets all organizational requirements. Demonstrates initiative to establish and achieve personal and professional goals.
Demonstrates effective customer service behaviors as defined by the organizations mission, vision and values.
Creates and implements discharge plan for every admitted patient. Assess each patient\'s medical, functional, psychosocial, legal/financial and safety/status, including self-care and environmental factors.
Develops discharge plan tailored to the patients\' needs and problems. Collaborates with physician, nurses and other ancillary staff, multidisciplinary team to make recommendations for effective, appropriate patient management.
Collaborates and communicates with the Social Worker as an ongoing process. Makes referrals to Social Worker as appropriate.
Identify and refer patient and family to resources specific to patients’ needs and problems, such as agency and private caregivers, equipment, mental health, and psychosocial resources, transportation, medical and housing resources and educational materials.
Implement the discharge plan and referral to services. Identify and resolve delays and obstacles to discharge. Acts as the primary leader of the discharge plan.
Using approved criteria, conduct admission and concurrent chart reviews for Medicare/Medicaid/and managed care payers with appropriate time frame to ensure appropriateness of level of care.
Monitor length of stay and other ancillary resources use on an ongoing basis. Identify opportunities for process improvement and recommend actions. Monitor on an ongoing basis avoidable days.
Communicates following the chain of command regarding proper utilization of resources, physician concerns, length of stay activities.
Coordinate with the department in-house liaison to assure third party certifications when required. Provide information as required regarding denials/approvals. Expedite the peer-to-peer process through collaboration with physician and insurance companies.
Communicate denials, verbally and in writing to patients, family, physician as needed.
On a concurrent basis, enter all pertinent data (discharge plan, UR and other areas as assigned) in data collections system as per policy/established process.
Participates in clinical performance improvement activities as needed and as assigned. Completes readmission interviews with patients/families to help determine cause of readmission. Enters information into appropriate systems
Understands the intricacies and can interpret/negotiate with state, local and federal agencies to optimize placement of patients in the most appropriate setting. Assesses and aligns the needs of patients with placement option that are consistent with desired level of care.
Works within the CMSA standards of practice.
Employee must be proficient in his/her jog responsibilities at the end of 90 days.
Education and Experience Minimum Required Education: RN licensure required
Preferred Education: BSN
Experience: At least three years of clinical nursing experience required. Utilization management, discharge, planning, home health, and/or ambulatory experience preferred. Knowledge of database, internet, spreadsheet and word processing software preferred.
Certifications, Licenses, Registrations CCM, ACM or related certification required within 2 years of eligibility for the exam (preferred)
Qualifications Education
Associates
Bachelors
Experience
Required 3 years
clinical nursing experience
Licenses & Certifications
Required
Certified Care Manager
Accredited Case Manager
Equal Opportunity Employer
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