RN Case Manager
Responsible for coordinating and monitoring the patient's care including the daily plan and the plan for the stay. Performs patient care review activities including monitoring and correcting patient status, documentation for medical necessity of admission and continued hospitalization and concurrent review. Educates patients and families about their hospital course and identifying patient's discharge needs.
1. Provide initial and ongoing assessments of the patients' needs for services in collaboration with the healthcare team. Monitor and evaluate utilization of those services to focus on the best treatment and approach for the patient promoting the timely progression of interventions, utilization of resources and expected outcomes within a length of stay consistent with external regulations and standards.
2. Provide utilization management including facilitating appropriate status assignment per Medicare and InterQual criteria. Ensure appropriate documentation for medical necessity of admission and continued hospitalization. Ensure appropriate level of care bed assignment, apply/interpret payer criteria to ensure conformance with payer standards and provide insurance reviews. Implement opportunities to improve effectiveness in utilization.
3. Provide transition planning coordination to include identifying needs and implementing referrals to other clinical care providers. Evaluate patient progress and revise the care plan if needed. Act as a resource for physician office, physician and staff regarding Intensity Severity Discharge (ISD) criteria. Identify barriers to achieving patients discharge and assist the care team in overcoming them.
4. Provide patient/family education to facilitate an understanding of their hospital and post-hospital course, their status assignment and discharge appeal rights and provide advocacy for their care.
5. Effectively communicate and provide clear and concise documentation according to department standards and regulatory requirements. Refer to appropriate internal and community resources as necessary.
6. Act as care management resource by demonstrating critical thinking, portraying a professional image of competency to customer and staff and demonstrating effective verbal and written communication with everyone. Maintain knowledge of CMS, Medicaid, and regulatory agency standards, Department of Health (DOH), Emergency Medical Treatment and Active Labor Act (EMTALA). Serve as a clinical resource and/or liaison.
7. Perform other related duties as may be assigned.
- Graduate of an accredited school/college of nursing and ability to successfully pass a clinical competency exam.
- BSN preferred.
- Minimum three years in a hospital setting with medical/surgical experience with supervisory/preceptor experience (or may have equivalent combination of education and/or experience).
- One year surgical patient population experience preferred.
- Discharge planning, case management, quality assurance/quality improvement, clinical documentation and/or utilization management using Intensity Severity Discharge (ISD) preferred.
- WA State RN Licensure.
- Basic Life Support (BLS) for Healthcare Providers required upon hire.
- Certified Case Manager (CCM) preferred.
- Strong verbal, written and interpersonal communication skills.
- Extensive knowledge of diseases, clinical procedures, treatment, prognosis and hospital functions.
- Ability to effectively communicate clinical information.
- Strong analysis/problem solving skills.
- Skill in the evaluation of quality and appropriateness of care.
- Proven leadership ability. Strong organization skills with the ability to work in a fast-paced environment independently or as part of an interdisciplinary team.
- Computer skills to include proficiency in keyboarding and data entry.
- Critical thinking skills, able to assess, evaluate and teach.
- Knowledge of discharge planning, health care reimbursement, utilization review processes and Medicare admission status/classification level.
- MS Office proficiency preferred.
Founded in 2004, Peak Health Solutions is a health information management services leader providing customizable solutions in the areas of medical coding and compliance. Our proven service offerings include; Outsourced Remote Coding, Auditing Services, Education Services, Clinical Documentation Improvement, and ICD-10 services including Gap Analysis, Education, Backfill Support, and Project Management. Peak Health Solutions delivers a superior set of solutions to hospitals that are some of the largest and most prestigious in the country. Peak's management team is comprised of highly skilled and experienced Coding Managers and health information management experts.
Our purpose is to provide HIM professionals with long-term, dependable, and flexible career opportunities by helping healthcare providers classify and improve clinical documentation to ensure accurate outcomes and timely reimbursement.
Fri, 5 May 2017 05:15:51 PDT