New Hanover Regional Medical Center Case Manager-RN - Case Management in Wilmington, North Carolina

Case Manager-RN - Case Management

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Case Management





Job Details

This position has access to and knowledge of extremely sensitive, private and confidential materials. Ability to maintain the highest standard is required with zero tolerance. All the primary duties within this document will be performed according to established policies, procedures and guidelines within the department and the Medical Center. JOB SUMMARY: The Case Manager is a professional Registered Nurse with strong clinical knowledge and leadership skills who works under the supervision of the Manager. Collaborates with the patient (all developmental stages), family, physician and interdisciplinary team and payer to plan, organize, coordinate and monitor the provision of cost-effective care in the most clinically appropriate setting, ensuring quality health care services and resources needed to promote optimal outcomes (clinical, functional, financial, satisfaction). PRIMARY JOB DUTIES: 1. Assesses the health status of patients assigned to caseload including data from history and physical assessments, interview with patient/family to determine care needs related to the medical diagnosis, treatment options, financial resources, educational needs, psychosocial needs and discharge planning. 2. Utilizes developmentally appropriate medical necessity criteria to perform admission and continued stay review in order to determine the appropriateness and medical necessity for hospital care and patient status. Issues Admission and Continued Stay Denial Letter as appropriate. 3. Assists the physicians in identifying alternatives to admission for cases that do not require acute care. 4. Educates physicians to insure compliance with the Utilization Management Plan for the hospital. 5. Refers cases not meeting defined level of care criteria to the Attending Physician for review and intervention when necessary. Consults Physician Advisor when appropriate. 6. Makes daily patient/family rounds, maintaining communication with physicians, patient care providers, and other team members regarding treatment plans in order to ascertain appropriate level of care, coordinate timely delivery of services, assist staff in identifying and addressing the learning needs of patients and families, and identify potential quality of care issues and refer these to appropriate management staff. 7. Assists staff in clinical decision making and priority setting to ensure an optimal hospital length of stay 8. Coordinates care for a defined patient population to assure optimal outcomes including appropriate LOS, cost containment, and customer satisfaction. 9. Educates the patient/family, and care providers throughout the continuum of care regarding the care expectations for the patient population. 10. In partnership with Utilization Management Team maintains awareness of current reimbursement issues as they relate to the patient population. 11. In collaboration with the health care team, coordinates discharge services, educates patient/family regarding coverage of discharge services and maintains compliance in arranging services. 12. Participates in performance improvement activities based on the patient population by identifying barriers to care, systems and process issues, and contributing to data collection and analysis for improvement plans. 13. Develops collaborative relationships with other departments, entities, and external health care agencies to facilitate and support quality of care. 14. Demonstrates strong communication skills that are effective in working with a variety of persons, including the patient, public, coworkers, guests, payers, outside agencies and medical staff. 15. Acts as a clinical/educational resource for patients, families, interdisciplinary team members and payers. 16. Organizes and performs work responsibilities effectively and efficiently. 17. Demonstrates the Standards of Performance (ownership, communication, teamwork and compassion) that support patient satisfaction and principles of service excellence. 18. Performs other duties as assigned. ESSENTIAL JOB SPECIFICATIONS: 1. Education: Graduation from accredited School of Nursing; BSN or Bachelors degree in a related field or 10 years of experience as an RN required. BSN or Bachelors degree preferred. 2. Licensure / Certifications: Current license to practice professional nursing in State of North Carolina. Certification in Case Management, or clinical specialty preferred. 3. Experience: Minimum of 5 years experience as an RN or 5 years combined RN and relative CM experience required. (10 years if no BSN or Bachelors degree in a related field) Must be able to demonstrate expertise in a clinical specialty for defined patient population. Indeed Nursing