Care Manager-RN (IL)

J  o  b    D  e  s  c  r  i  p  t  i  o  n

          Joy                         Care                      Competence                    Respect

Position Summary

In collaboration with the patient/family, social workers, physicians, interdisciplinary team, and payer representative, the Care Manager-RN ensures patient progression through the continuum of care in an efficient and cost effective manner. Identifies, initiates and manages optimal care coordination and discharge planning to develop  patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety and length of stay management. Provides support and expertise through comprehensive assessment, planning, implementation and overall evaluation of individual patient needs. Monitors the provision of cost effective care to ensure care is given in the most clinically appropriate setting. Facilitates compliance with regulatory requirements and organizational performance standards, including demonstration of core competencies.

Associate’s Degree or Diploma in Nursing is required.

Bachelor’s Degree in Nursing is preferred.

2 years of clinical experience is required.

Prior case management experience is preferred.

Quality/Process Improvement experience is preferred.

License as a Registered Nurse (RN) in the state of practice is required.  Wisconsin:  RNs may practice with a valid multi-state RN license as outlined in the Nurse Licensure Compact rules.

Case Management certification (ACM, CCM, RN-BC) is preferred.

Basic Life Support Certification (BLS) is required within 60 days of hire.

Ability to communicate effectively both orally and in writing with diverse populations.Provides excellent customer service skills through telephone, personal and/or written communication.

Demonstrates strong critical thinking, diplomacy, problem-solving and multi-tasking skills.

Significant knowledge and understanding of availability of community and post-acute resources.Knowledge of federal and state regulations (DOH, Medicare/Medicaid).Knowledge of third-party payers and/or managed care principles.Demonstrates competence in computer systems and applications required for the role.

Including but not limited to Epic, Optum portal, insurance portals and MCG.

Coordinates the integration of case management functions into the patient care, discharge planning processes in collaboration with other hospital departments, external service organizations, agencies, and healthcare facilities. Uses established medical necessity criteria and as described by policy, conducts screenings for appropriateness of admission (Inpatient, Outpatient, Observation) and continued stay medical necessity elements of clinical and demographic information for accuracy and completeness.  Proactively interfaces with payer, were required, to ensure that hospital meets payer requirements for observation or inpatient services in instances when insurance information/coverage seems unclear or unfamiliar. In collaboration with the patient/family, physicians and interdisciplinary team, the care manager ensures patient progression through the continuum in an efficient and cost effective manner

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. 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. Coordinates and implements the coordination of care and discharge plan for patients with post-care needs (i.e., home health, DME, transfers to SNF, etc.) in collaboration with the Social Worker. Identifies and communicates relevant information to the care team related to patients frequently seen or frequently re-admitted

Reviews and analyzes LOS, resource utilization, outliers, readmissions, denials, and delayed days for assigned patients. Issues Medicare Notices of Noncoverage and assists in appealing insurance denials for assigned units and communicates with the Finance Department to support and ensure accurate billings, proactive audit and denial management.

Possess the information, skill, and understanding of the work to be performed.  Actively participates in continuing education opportunities and maintains certifications, licensure as appropriate.

Reduces the risk of healthcare acquired infections through compliance with current CDC hand hygiene guidelines and facility policies including the wearing of Personal Protective Equipment (PPE), if applicable.  Utilizes standard precautions during patient contact and when handling contaminated materials.  Demonstrates compliance with National Patient Safety Goals.

Complies with all standards, policies and procedures including dress code, attendance and punctuality.  Attends required in-services and meetings and completes all mandatory competencies by deadline.  Commits to keeping all patient, student or colleague information confidential and maintains excellent interpersonal communication with the health care team colleagues.

Emphasizes a holistic approach to patient care-attending to body, mind, and spirit while upholding ethical principles with patient care and all other aspects of work.  Actively involves the patient and family in decisions about care.  Promotes quality care by participating in organizational councils/committees and/or support of related process.  Documents services provided to patients in the electronic medical record in accordance with policy and requirements. 

The purpose of this job description is to provide a summary of the major responsibilities performed by colleagues in this position. Colleagues may be requested to perform tasks other than those specifically presented in this job description.  Variances in job duties performed may exist between facilities, and colleagues may perform other related duties as assigned to meet the needs of the organization.

PHYSICAL, MENTAL AND ENVIRONMENTAL REQUIREMENTS

Physical, Mental and Environmental Requirements Category:

Clinical

Standing

X

Walking

X

Sitting

X

Lifting

X

50 lbs.

Carrying

X

50 lbs.

Pushing

X

50 lbs.

Pulling

X

50 lbs.

Climbing

X

Balancing

X

Stooping

X

Kneeling

X

Crouching

X

Crawling

X

Reaching

X

Use of Hands/Dexterity

X

Talking

X

Hearing

X

Eye/Hand/Foot Coordination

X

Extreme Cold

X

Extreme Heat

X

Humid

X

Wet

X

Positions in this category may experience wet

conditions in his/her work environment

Noise

X

Positions in this category may experience a higher

noise level in his/her work environment.

Hazards

X

Temperature Change

X

Positions in this category may experience a

temperature change in his/her work environment

Atmospheric Conditions

X

Vibration

X

Other