HEALTH QUEST IS AN EQUAL OPPORTUNITY EMPLOYER.
Under the general supervision of the Director, The Nurse Case Manager role provide clinically-based case management to support the delivery of effective and efficient patient care. Paces the case from physiological and economic perspectives. Has overall accountability for the utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement. Utilizes criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, creates a discharge plan appropriate to the patient's needs and resources.
Essential Duties and Responsibilities:
- Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria, computer system or third party information to resolve the situation. Documents information in the current electronic system (such as MIDAS).
- Validates admission and continuing stay criteria with third party payers (including onsite and telephonic Case Managers) as well as Primary Care and Attending Physicians. Recommends alternative care sites where appropriate.
- The observation cases are a priority and at a minimum the case manager reviews observation cases daily.
- Utilizes physician advisor to interface with physicians as needed.
- Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent the denial where possible.
- Supports the effective prevention and management of denials, including providing information as part of the appeal process.
- Serves as the lead in obtaining financial and other resources for patients/families in need.
- Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a plan for discharge.
- Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan. Supports the process of patient choice in establishing a discharge plan.
- Uses clinical knowledge and knowledge of anticipated response to treatment to assess patient progression towards anticipated outcomes. Communicates and coordinates with the patient/family and health care team to Intervene when progression is stalled or diverted. Addresses actual/potential barriers to discharge.
- Provides support and counseling to patients/families experiencing and/or anticipating issues to adjusting to illness, catastrophic diagnoses, changes in living situations and bereavement. Establishes a plan and documents interventions and outcomes.
- Completes the interventions necessary for discharges to home with self-care, home with services and short term skilled nursing facility placement. Assembles necessary referrals, discharge summaries and pertinent information for placement prior to the day of discharge.
- Consults, assesses, refers, coordinates interventions in cases of suspected or actual situations of child or adult abuse and neglect or other forms of domestic violence and/or sexual abuse.
The nurse case manager may provide case management services in the ED and or for the pre-surgical population as described below:
The Case Manager screens selected patients referred to the Admitting Office to determine the appropriate level of care through the use of clinical criteria, the Medicare Inpatient Only List and individual payer requirements.
The Access Case Manager assesses, plans, coordinates, and evaluates initial and ongoing patient registration processes and data that promote accurate and timely patient classification and authorization for services and/or patient acknowledgement of outpatient non-coverage at Health Quest. He/she is devoted to improving ongoing patient classification processes and performance outcomes and is responsible for concurrent collection, analysis and reporting of data, in addition to communication, and ongoing education.
The Case Manager works with ED personnel to identify the appropriate level of care based on InterQual/Milliman criteria being hospitalized. The ED case manager is responsible for identifying if medical necessity is met for in-patient or observation. The case manager assesses patients and families for discharge needs whether they are going home from the ED or being admitted to the hospital. The ED case manager has an understanding of the regulatory requirements and assures that the regulatory requirements are met. The ED case manager understands levels of care in the community and discharges patients appropriately from the ED to the appropriate level of care based on the patient's payer
Minimum Acceptable Qualifications:
Case Mgmt 1-3 yrs exp. required
NYS RN License