$20,000 Bonus plus Relocation Eligibility!

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Coordination of Care

Job Family

Nursing

Work Shift

Summary

The COC RN Case Manager comprehensively plans for continued care services, in conjunction with the Advanced Practice provider and physician. Carries out activities related to utilization review, discharge planning, care coordination and referral to other levels of care. Works with care team to facilitate use of clinical guidelines and achievement of desired treatment outcomes in a timely and cost-effective manner. Participates in multidisciplinary rounds and promotes interdisciplinary collaboration with all team members. Works collaboratively to ensure patients needs are met and care delivery is coordinated across the continuum at the appropriate level of care. Adheres to the patient experience initiatives and champions customer service.

MAJOR JOB FUNCTIONS:

Performs the initial assessment on all patients within one day of bedding, using the appropriate clinical criteria set or in accordance with CMS rules and regulations for initial and concurrent stay reviews.  Reviews physician orders for level of care status against patient in the hospital’s registration system to ensure accuracy.

If conflict arises, initiates action to resolve the discordant orders

Ensures the chart coincides with the review or CMS rules and regulations for appropriate level of care and  status on all patients. Assesses the patient’s plan of care within one day of presentation and re-evaluates the plan of care, at least every 72 hours, utilizing the appropriate criteria set to determine medical necessity and level of care requirements. Contacts attending physicians for additional information if the patient does not meet the appropriate screening criteria, or in accordance with CMS rules and regulations for continued stay. Collaborates with and makes referrals to physician advisor when unable to resolve issues with attending physician. Adhere to Medicare Condition Code 44 process.  Issues Medicare Outpatient Observation Notice (MOON) promptly to ensure timely notification to patients. Coordinates with registration/bed placement departments and physician offices to assure pre-certification authorizations and supporting documents are obtained when required. Reviews patient medical record, for third party payors, and provides clinical information to support admission and continued stay reviews.  Sends pertinent clinical information, as requested, to payor.  Responds to calls for information from payors and follows up on existing payor requests in a timely manner. Confirms with payor that notification process has been completed within contracted time requirements. Contacts payor as needed to follow up on all continued stay authorizations, entering pertinent clinical reviews and authorization information into the system, until the patient is discharged.  Assist with post discharge authorizations as needed. Communicates payor concerns or requests, such as peer to peer reviews, payor requested observation status changes, for additional information to appropriate physician and physician advisor and ensures timely follow up by physicians. Sends billing communication to designated PFS and HIM team members to ensure accurate billing designation based on physician advisor recommendations and final status order.  Provides proper notification to attending physician for all billing variances. Assists with medical necessity reviews for denial and appeal purposes. Conducts initial interviews with patients/family, as soon as possible, but not greater than 2 days of admission to formulate a plan of care and coordination of services, in collaboration with the physician/advanced practice provider, based on clinical needs and available resources to facilitate appropriate transition to the next level of care.  Documents assessment, the ongoing plan of care, case progress, intervention (s) and reassesses patients, as needed according to facility requirements, licensure, and regulatory requirements. Assesses and evaluates the medical necessity and appropriateness of ancillary testing, medications, treatment, and plan of care, discussing concerns with the involved physician, nurse, or ancillary staff member.  Makes appropriate referral to physician advisor regarding trends/areas of concern. Provides support and education to patient/family regarding illness process.  Assist patient/family in coping with hospitalization, disability, and chronic/terminal illness.  Makes referrals to social workers for complex discharge planning needs and emotional, social, and psychosocial components of patient illness. Ensures integration of the interdisciplinary team in understanding and integrating these aspects into the plan of care. Maintains current knowledge and researches availability of community resources and options for post-acute care appropriate to the age of the patient served.  Ensures that patients are provided a choice of post-acute care facilities per HIPAA regulations. Initiates referrals to community agencies as needed. Identifies and documents clinical and financial barriers to a smooth transition across the healthcare continuum and assists in identifying and facilitating system improvements. Understands placement intricacies and can interpret requirements from the local, state, and federal agencies to optimize placement of patients in the most appropriate setting.  Aligns needs of patient with appropriate placement options.  Initiates PASARR requests for placement timely, identifying barriers that may potentially delay the discharge process. Coordinates care to progress the patient through the healthcare continuum.  Initiates referrals, recommends consults, and takes necessary telephone orders to enable patient to be prepared for safe and timely discharge or transfer.  Ensures that patients have access to primary care provider and specialists are needed to optimize care transition success. Carries out discharge planning activities to include providing arrangements for Home Health, Hospice, Home Infusion, DME, OP Dialysis, Inpatient Rehab, LTACH, Assisted Living, Rest Home and Subacute Skilled Nursing Facility placements.  Tasks Discharge Planning Assistant with appropriate activities to coordinate the discharge plan within the scope of their practice. Makes timely referrals to Social Worker for, but not limited to, the indigent patient population, abuse or neglect inquiries, power of attorney, healthcare surrogate, or advance directive clarification or initiation of guardianship, involuntary commitments, long term placements, end of life care options and complex family meetings. Assures completion of discharge, to include Important Message from Medicare (IMM), Medicare Outpatient Observation Notice (MOON), EMTALA, PCS for stretcher transport or wheelchair transportation. Proactively monitors patient activity, identifying and resolving delay and barriers to discharge.  Monitors length of stay, readmissions, and documents avoidable days for trending and performance improvement purposes.  Refers outlier cases to the Coordination of Care Leadership Team, Medical Director/Physician Advisor, and Hospitalist Leadership Team members in a timely manner. Promotes patient quality outcomes by demonstrating timely, accurate clinical documentation and discharge planning interventions for all patients.  Charting is reflective of accurate clinical assessment, planning, coordination, facilitation and delivery of reasonable and safe discharge planning and care transition. Representative and point of contact for Medicare Appeal process.  Facilitates timely faxing of patient record for review as requested by the Quality Improvement Organization.  Issues Hospital Issued Notices of Non-Coverage (HINN) letters to beneficiaries as appropriate, and initiates escalation to Coordination of Care Leadership if Administrative discharge is required.  Provides alternate plan of care with the physician and the interdisciplinary team and communicates verbally to the patient/patient representative to optimize care transition process. Coordinates the plan of care with the physician and the interdisciplinary team and communicates verbally to the patient/representative to optimize care transition process. Adheres to mandates, standards, policies, and procedures as determined by federal, state, health system and department policy. Promotes positive customer service and service orientation in the performance of position duties and responsibilities and interactions with patients, hospital staff and visitors. Performs any additional duties within the scope of licensure that may be necessary to ensure appropriate patient care.  Enhances professional growth and development through participation in educational programs, current literature, in-services, meetings, and workshops. Functions as a role model and mentor.

ADDITIONAL RESPONSIBILITIES:

Serves as mentor for newly hired RN CMs. Participates in weekend and holiday rotation as required. Participates in quality improvement activities at the direction of the Leadership Team to improve processes and promote evidence-based practice. Other duties as assigned.

QUALIFICATIONS:

The following qualifications, equivalents of are the minimum requirements necessary to perform the essential functions of this job.

EDUCATION AND FORMAL TRAINING:  Associate degree in Nursing required, BSN preferred.  Must be licensed as an RN with current licensure in State of North Carolina.   Medical/Surgical and/or ICU experience preferred. Case Management experience preferred.

WORK EXPERIENCE:  Minimum two years’ experience in Acute Care setting required.

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED:

Critical thinking and clinical competence demonstrated at an above average level. Excellent interpersonal communication and negotiation skills.  Able to communicate effectively and work with people of all social, economic, and cultural background. Self-motivated, proven written, telephonic, and electronic communication skills, assertive and persuasive in interactions with customers, peers, management, and core staff served. Ability to discuss a patient’s clinical, socio-economic, and financial issues with physicians and patient and/or patient’s representatives. Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components. Skills necessary to build credible and effective relationships with physician leadership, the internal and external customers. Ability to prioritize and process multiple tasks, responsibilities, and work project, demonstrating strong organizational and time management skills. Proficiency in various computer programs, to include Microsoft Office and electronic medical record system. Ability to work and promote interdependence demonstrated in actions resulting in sound judgment with interactions with physicians, peers, patients and/or designee, payors, and support service personnel. Ability to demonstrate respect and team building. Flexible, open-minded, and adaptable to change.  Models positive change. Ability to work collaboratively with department staff, physicians, and healthcare professionals at all levels to achieve established goals, improve quality of outcomes, maintain, or exceed The Joint Commission (TJC) standards and state mandates as they apply to the department operations. 

PHYSICAL REQUIREMENTS:

Some light carrying and lifting may be required.  Occasional walking may be required to access all areas of the Medical Center.  Ability to effectively communicate verbally to patients, family members, personnel, and physicians.  Near visual acuity to proofread hand and typewritten materials.  Manual ability to use telephones and computer keyboards. 

Required Licenses and Certifications

RN - Board Of Nursing

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity