RN - Case Manager - Full-Time - AVALA Hospital - RH273

Summary

The role of Case Management RN directly oversees the coordination of Utilization Management activities in alignment with CMS regulations and Third Party reimbursement requirements; directs and assists the nursing staff with discharge planning needs by conducting daily continued stay reviews of patient population; works in a collaborative manner with executive staff, physicians, nursing staff, and support staff in identifying problematic issues to achieve desired goals and complete assigned projects. The Case Manager also works closely with the Director of Quality by participating in functions as assigned to support AVALA's quality management and education programs.

Essential Duties and Responsibilities

• Interacts continuously with physicians, caregivers and supportive staff to assure all physician orders clearly identify the appropriate level of care at point of entry.
• Assesses medical necessity of hospital stay that reflects a working knowledge of Medicare Compliance, Managed Care Contracts, and Third-Party Payer Criteria. Notifies physician when documentation does not support medical necessity level of care ordered.
• Evaluates levels of care and length of stay utilizing EMR.
• Identifies and addresses target issues/trends. Compiles reports for committees and administrative team. Actively participates on performance improvement opportunities.
• Communicates clinical criteria with insurance company, based on information received.
• Evaluates and screens potential admissions for appropriateness.
• Initiates ongoing communication with the patient and their family to assess discharge needs. Assesses social, environmental and financial factors influencing discharge plan.
• Communicates with physicians to ascertain their plans for a timely discharge.
• Plans and assists with referrals to appropriate community resources. Initiates discussions with physicians when a patient’s level of care warrants evaluation by a facility at a different level of care, such as a long-term care facility or rehabilitation center.
• Documents discharge planning within EMR.
• Ongoing interaction with clinical personnel, nurse managers, ancillary departments, and administrative team.
• Demonstrates awareness of the responsibilities of the position and how it interfaces with the rest of the healthcare team. Works closely with all department members as required, is flexible to meet the needs of the department and changes in the workload.
• Communicates appropriately and clearly to physicians, staff, nurse executive and administrative team.
• Consistently demonstrates a professional, self-directed, mature, disciplined and tactful approach to department responsibilities.
• Demonstrates an ability to be flexible, organized and function under stressful situations.
• Assists and provides back-up support to the Clinical Documentation Specialist as needed.

Core Competencies

• Action Orientation - Targets and achieves results, overcomes obstacles, accepts responsibility, establishes standards and responsibilities, creates a results-oriented environment, and follows through on actions.
• Communications - Communicates well both verbally and in writing. Effectively conveys and shares information and ideas with others. Listens carefully and understands various viewpoints. Presents ideas clearly and concisely and understands relevant detail in presented information.
• Creativity/Innovation - Generates novel ideas and develops or improves existing and new systems that challenge the status quo, takes risks, and encourages innovation.
• Critical Judgment - Possesses the ability to define issues and focus on achieving workable solutions. Consistently does the right thing by performing with reliability.
• Customer Orientation - Listens to customers, builds customer confidence, increases customer satisfaction, ensures commitments are met, sets appropriate customer expectations, and responds to customer needs.
• Interpersonal Skills - Effectively and productively engages with others and establishes trust, credibility, and confidence with others.
• Leadership - Motivates, empowers, inspires, collaborates with, and encourages others. Builds consensus when appropriate. Focuses team members on common goals.
• Teamwork - Knows when and how to attract, develop, reward, and utilize teams to optimize results. Acts to build trust, inspire enthusiasm, encourage others, and help resolve conflicts and develop consensus in creating high-performance teams.

Professional Requirements

• Meets dress code standards and adheres to dress code policy.
• Completes annual education requirements.
• Maintains regulatory requirements.
• Always maintains patient confidentiality.
• Reports to work on time and as scheduled, completes work within designated time.
• Wears identification while on duty.
• Completes in-services and returns in a timely fashion.
• Attends annual review and department in-services, as scheduled.
• Represents the organization in a positive and professional manner.
• Actively participates in performance improvement and continuous quality improvement (CQI) activities.
• Complies with all organizational policies regarding ethical business practices.
• Communicates the mission, ethics and goals of the hospital, as well as the focus statement of the department.
• Promotes professional growth of subordinates by sharing knowledge and/or directing them to sources if information appropriate to given situation. Utilizes journals, books, etc. to learn and/or improve new techniques and equipment.
• Assists other staff members in performing any duty that enhances the delivery of patient care.

Advanced Orthopedic and Spine Certification Requirements

(CR.1c) As part of the Advanced Orthopedic and Spine Certification, at a minimum, the Program direct-care staff, must have eight (8) hours of education specific to the Program scope, initially, and at least annually thereafter.

(CR.1e) As part of the Advanced Orthopedic and Spine Certification, staff possess adaptability to processes as related to up to date best practices, collaboration between departments, compliance with protocols/processes, communication, cooperation and exceptional customer service.

Within 90 days of hire or, if currently employed, within 90 days of signing the job description, must adhere to:

Orientation of Advanced Orthopedic and Spine Certification

In compliance with the Program education requirements

Completed department specific competencies

Regulatory Requirements

• Graduate of accredited school of nursing
• Current state Registered Nurse Licensure, within state of practice.
• Current BLS
• ACLS certification recommended

Skills

• Current with all skills as assigned in Health Stream.
• Possesses language skills to communicate effectively in English, both verbally and in writing.
• Basic computer knowledge.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. This position is very active and requires repetitive motions, standing, walking, bending, kneeling and stooping all day. The employee must frequently lift or move items weighing up to 50 pounds.