RN Acute Case Manager - System Care Management - Per Diem

Position Summary:
The Acute Case Manager utilizes industry accepted processes for achieving optimal patient, clinical, and operational outcomes timely, coordinated, and in cost effective manners. The Acute Case Manager has the responsibility, accountability, and authority for coordinating the medical management of hospital patients, using outcomes-based approaches. The Acute Case Manager supports the healthcare team in assessing, planning, and facilitating individualized continuum of care plan for patients, based on assessed needs and available resources. The Acute Case Manager monitors clinical approaches and make recommendations for alternate levels of care. The Acute Case Manager also performs Utilization Management throughout the continuum of care in collaboration with other internal and external offices, payors, and providers. The Acute Case Manager collaborates cooperatively with the patient and members of the interdisciplinary health care team. The Acute Case Manager takes a proactive approach to ensuring the integration of both clinical and operational outcomes through analysis of clinical and financial data, including length of stay and DRG profiling.
Education, License & Cert:
RN Bachelor of Science degree in Nursing (BSN) or, a Bachelor of Arts (BA) degree in addition to a degree in Nursing. A registered nurse with five (5) years relevant experience willing to pursue a BSN or BA degree will be considered. Must obtain BSN within two (2) years of hire. Individual consideration may be given to a registered nurse, with significant clinical experience, who holds a bachelor’s degree in a related field.
Experience:
BSN or BA with a minimum of five (5) years relevant experience who demonstrates leadership and autonomy in nursing practice. a) Utilize critical thinking skills to create and or develop a clinical program or position and b) Demonstrated leadership skills for a licensed degree exception, there must be a significant depth of clinical experience: five (5) years of experience in an acute care setting with strong care management, utilization review, and payer knowledge. A Case Management certification or obtaining a Case Management certification within one (1) year of eligibility is encouraged.
Essential Functions:
1) The Acute Case Manager collaborates to support that the right care is provided to patients in the right setting with a broad spectrum of health and community providers.
a) Works closely with the Medical Director and other members of the healthcare team to provide appropriate medical management and resource utilization utilizing established/approved criteria.
b) Educates the physician and other healthcare team members regarding the coordination of care processes of the patient across the continuum of care.
c) Entity specific acute case manager may need to participate in an on‐ call system to ensure 24‐ hour accessibility and accountability to meet patient needs.
d) Serves as patient advocate in representing the patient’s best interests to the providers.
e) Procures insurance authorizations where indicated to ensure appropriate, cost effective care.
f) Acts as an institutional advocate by managing care in a cost-effective manner and communicating with third party payers.
2) Coordinates medical management through ongoing interaction with the patient and family/caregivers, physician and other health care providers to achieve designated clinical, operational and financial outcomes.
a) Facilitates clinically appropriate treatment and coordinates flow of services by acting as a focal point for communication for healthcare team members, patient, provider, and payer.
b) Supports development, integration, and monitoring.
c) Maintains accountability for coordination of care processes for the patient during the acute care phase, and during the transition phase to outpatient services.
d) Initiates and participates in patient care conferences as appropriate.
e) Completes nursing assessment forms in the system.
f) Addresses PRI and other referral procedures as needed for continuing care needs.
g) Provides leadership for clinical staff regarding complex patient care concerns and/or care of patients who do not achieve expected outcomes.
3) Identifies individual patient discharge needs in collaboration with other clinical team members beginning upon initial admission assessment and continued reassessment throughout an episode of care. Takes the initiative in working with the interdisciplinary health care team and patient/family to identify a treatment regime which streamlines care, reduces or controls costs and enhances patient outcomes.
a) Assists in the implementation of discharge planning as necessary, through concurrent monitoring and reevaluation, to accommodate changes in treatment or progress. Anticipates changes in treatment and develops contingency plans.
b) Ensures patient understanding of rights, choices, and consequences.
c) Completes referral procedures to the appropriate institutional, community, or specialized resources.
4) Integrates patient information, clinical/financial/operational data and evaluates the impact upon patient, clinical, and financial outcomes. Identifies opportunities to continue or reduce costs and optimize case reimbursement.
a) Identifies cost/clinical outlier patients for intensive case management and facilitates evaluation of alternative care options.
b) Maintains compliance with documentation requirements and guidelines of third-party payers, regulatory and government agencies.
c) Participates in long‐ range planning to meet the needs high risk patients and/or population.
5) Demonstrates leadership skills including effective written and verbal communication, conflict resolution, problem solving and critical thinking, organizational and time management skills and appropriate delegation.
a) Develops and promotes collaborative relationships with other members of the Guthrie Healthcare System Enterprise and community resources, including home health agencies, DME companies, nursing homes, etc., to explore alternate care options to meet identified patient care needs.
b) Maintains a positive and professional relationship with payers that supports continued managed care contracts.
c) Articulates the primary objectives of Care Coordination processes to all members of the health care/leadership team and others as necessary.
6) Participates in performance improvement and educational activities.
a) Incorporates available current evidence-based data for clinical care management.
b) Demonstrates knowledge of federal, state and system regulations and aligns practice to comply with such.
c) Serves as an educational resource for other members of the healthcare team in regards to changes in reimbursement and /or utilization requirements.
d) Maintains 8 hours of continuing education per year.
e) Contributes to Performance Improvement (PI) activities through both individual and aggregate data monitoring. Initiates and provides leadership for performance improvement activities as appropriate based upon outcome data and or problematic issues.
7. Validates authorization/certification process for elective short procedures and urgent inpatient care services in collaboration with physician offices and other hospital departments as appropriate.
a. Screen the appropriate level of care or service for hospital inpatient admissions and short procedures by translating clinical information to Utilization Management requirements using pre‐ determined criteria.
b. Documents UR findings in appropriate computer system and screen.
c. Utilizes reports and other mechanisms to identify cases for UR screening and follows procedures for follow up as necessary.
Other Duties:
1. It is understood that this description is not intended to be all‐ inclusive and that other duties may be assigned as necessary in the performance of this position.
2. Travel for this position is sometimes required.
3. Participation in community and employee engagement activities is required.