The purpose of the Case Manager I position is to support the physician and interdisciplinary team in facilitating patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payors. The role integrates and coordinates utilization management and care facilitation.
1. Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement
2. Application of process improvement methodologies in evaluating outcomes of care
3. Coordinating communication with physicians
4. Coordinates/facilitates patient care progression throughout the continuum.
· Works collaboratively and maintains active communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely, appropriate patient management.
· Address/resolves system problems impending diagnostic or treatment progress. Proactively identifies and resolves delays and obstacles.
· Seeks consultation from appropriate disciplines/ departments as required to expedite care.
· Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
· Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated case load; monitors the patient's progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis
· Modifications of plan of care, as necessary, to meet the ongoing needs of the patient;
· Communication to third party payors and other relevant information to the care team;
· Completion of all required documentation in the EHR and patient records
5. Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
6. Completes Utilization Management and Quality Screening for assigned patients.
· Identifies at-risk populations using approved screening tool and follows established reporting procedures.
· Refers case and issues to Care Management Medical Director in compliance with Department procedures and follows up as indicated.
· Discusses payor criteria and issues on a case-by-case basis and follows up to resolve problems with payors as needed.
· Uses quality screens to identify potential issues and forwards information to Clinical Quality Review Department.
7. Ensures that all elements critical to the plan of care have been communicated to the patient/family and member of the healthcare team and are documented as necessary to assure continuity of care.
· Collaborates/communicates with internal & external case managers.
· Initiates and facilitates referrals for home health care, hospice, medical equipment and supplies.
· Facilitates transfer to other facilities as appropriate.
8. Actively participates in clinical performance improvement activities.
· Assists in the collection and reporting of resource and financial indicators including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials and appeals.
· Uses data to drive decisions and plan/implement performance improvement strategies related to case management for assigned patients, including fiscal, clinical and patient satisfaction data.
· Collects, analyzes and addresses variance from the plan of care/care path with physician and/or members of the healthcare team. Uses concurrent variance data to drive practice changes and positively impact outcomes.
· Collects delay and other data for specific performance and/or outcome indicators as determined by Director or Manager of Case Management.
· Documents key clinical path variances and outcomes which relate to areas of direct responsibility. Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently.
9. Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.
10. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization; serves as a preceptor, mentor, and resource to less experienced staff.
11. Other duties as assigned.
Demonstrate Standards of Behavior and adhere to the Code of Conduct in all aspects of job performance at all times.
- Current and valid license to practice as a Registered Nurse RN in the state of Washington.
- Excellent interpersonal communication and negotiation skills
- Strong analytical, data management and PC skills.
- Understanding of venues of care and community resources.
- Professional certification as a Case Manager encouraged within three years of employment.
- One year clinical experience preferred.
- Current working knowledge of utilization management, case management, performance improvement and managed care reimbursement preferred