Care Manager RN – Full Time, Days

Utilization Management

•   Demonstrates accountability for utilization management functions and communication with payers to assure authorization and payment for hospital stay.
•   Performs admission review within 24 hours of admission on all patients in case load utilizing InterQual Criteria to determine if patient meets medical necessity for admission.
•   Initiates contact with attending physician to solicit additional information to support medical necessity for admission when there is not adequate information in the medical record.
•   Suggests alternative level of care/treatment plan for patients not meeting medical necessity for admission.
•   Refers cases for second level review that do not meet medical necessity or level of care requirements, according to department procedure.
•   Documents review in Soft Med according to department procedure.
•   Submits reviews to third party payors according to contract requirements in a timely manner.
•   Assures days are approved and information is entered in Soft Med in a timely manner.
•   Follows up with third party payors when there is a lack of response to request for authorization.
•   Advocates for the patient, family, physician, and facility to obtain benefits from third party payors and others that provide financial assistance.
•   Communicates with patients and families to ensure understanding of third-party payor guidelines.
•   Conducts continued stay review as indicated based on clinical condition and third party payor requirements.
•   Collaboratively institutes prevention plans to avoid third party payor denials and problems solves with the health care team when denials are received.
•   Manages concurrent denial/appeal process in collaboration with the UR Specialist.
•   On a concurrent basis, assesses the appropriateness and timeliness of the level of care, diagnostic testing and clinical procedures, quality and clinical risk issues, and documentation completeness.
•   Issues denial letters as indicated according to department procedure.
•   Acts collaboratively to resolve resource issues, keeping manager/director informed as needed.
•   Refers cases with complex psychosocial and medical issues to the social worker according to department guidelines.
•   Communicates with the attending physician to clarify information regarding the plan of care as needed.
•   Escalates cases not meeting continued stay criteria or when an alternative level of care is more appropriate when barriers to care progression are unresolved, according to department procedure.

Discharge Planning

•   Leads and implements the transition planning process from the time of admission to discharge by effectively assessing patient/family needs, preferences, and available resources.          

•   Completes a discharge planning assessment for all patients in assigned case load within 24 hours of admission.
•   Confers with attending physician and other members of the health care team to identify needs.
•    Documents all pertinent information in the electronic medical record.
•   Serves as a resource and advocate for patients/families by providing information regarding available resources appropriate for the patient’s discharge plan and third party payer guidelines.
•   Communicates with patient/family to ensure understanding of anticipated discharge date and involvement in planning for care after discharge in a consistent and timely manner.
•   Refers cases with complex psychosocial and or medical issues that may create barriers to discharge to the social worker according to department guidelines.
•   Completes the PRI in a timely manner as indicated.
•   Initiates referral to facilities and agencies that can meet the post hospital care needs of the patient and are authorized by third party payors.
•   Ensures patients’ right to choice in providers of post hospital care by providing a list of agencies and facilities that can meet the patient’s care needs.
•   Ensures continuity of care by acting as a liaison between the hospital and community resources.
•   Provides all required information to the agency/facility to facilitate a smooth transition.
•   Maintains positive working relationships with community agencies and facility staff to maximize access for patients/families.
•   Keeps up to date on available community resources and regulatory requirements that impact discharge planning.
•   Provides input to the development of processes that improve continuity, transitions, and patient centered care across the continuum of care.

Care Progression

• Identifies anticipated discharge date at the time of admission in collaboration with the members of the health care team.
•  Ensures that the patient/family is aware of the plan of care and anticipated length of stay.
• Monitors patient’s plan of care and progress in relation to anticipated length of stay and intervenes to facilitate a timely discharge.
• Attends daily Patient Care Progression Rounds and follows up on any issues/barriers identified with the appropriate staff/departments.
• Facilitates communication among team members to resolve issues that may impact the plan of care.
• Encourages interventions appropriate to the reason for the patient’s admission.
• Initiates referrals to the appropriate areas to expedite care, treatment, and services ( SW,PT, speech therapy, financial counselor, palliative care, etc.)
• Seeks input from clinical experts to explore acceptable alternatives to treatment plan.
• Identifies and documents avoidable delays in care and works collaboratively the healthcare team to prevent them.
• Escalates cases with unresolved issues according to department guidelines.