Description
Job Description
Position Summary:
The individual in this position has overall responsibility for coordinating the daily activities of the case management team, while overseeing the clinical plan of care to conform with evidence-based practice and/or regulatory/payer requirements. This position integrates functions typically considered to be case management, care coordination and/or utilization management, and discharge planning assessment and coordination.
· Provides assistance to the Director of Case Management in the management of the department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments
· Utilization Management supporting medical necessity and denial prevention
· Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
· Care Coordination by demonstrating efficient throughput while assuring care is sequenced and at the appropriate level of care
· Accountable for compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
· Provides education to physicians, patients, families and caregivers
· Facilitates educational programs for Case Management Department on community resources use in discharge planning that encourages professional growth
· Provides reports to DCM and hospital leadership as requested
Essential Duties:
· Coordination of clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post-acute care) compared to evidenced-based practice, internal and external requirements.
· Identify and report variances in appropriateness of medical care provided, over/under utilization of resources compared to evidenced-based practice and external requirements. This priority includes work with relevant software and communicating information through clear, complete and concise documentation in CM software.
· Effective collaboration with physicians, nurses, ancillary staff, payers, patients and families to achieve optimum clinical outcomes.
· Remain current with relevant clinical / case management practices.
· Assist Director with daily operational oversight and supervision of Departmental staff.
· Other duties as assigned by department director
Training Requirements
Must complete Tenet's InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Attendance at hospital and department orientation is required. Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQual®, Transition Management, Utilization Management, and other topics specific to case management.
PRIMARY INFORMATION, TOOLS AND SYSTEMS USED
· Patient data – hospital admission, discharge, transfer system
· Healthcare staff documentation related to patient care
· Regulatory and payer requirements
· Allscripts ®, MIDAS & other Care Management Documentation Systems
McKesson Care Enhance Review Manager (CERMe) InterQual system
· Clinical data interface and secure faxing
· Patient Medical Record including Cerner, Mc Kesson, Meditech, EPIC and HPF
· Hospital specific Clinical Software
POSITION SPECIFIC RESPONSIBILITIES:
Department Operations
· Oversees an adequate number and skill mix of staff over seven days a week to serve the patient population and meet the goals of the department
· Supports and manages staffing requests utilizing the Tenet Case Management staffing recommendations within budgetary guidelines
· Plans and conducts regular departmental meetings with the Director to provide staff updates and ongoing education
· Assists the Director with the implementation of the InterQual Inter-rater Reliability (IRR) Policy to determine initial and yearly competency for all employees performing InterQual reviews
· Ensures new Case Management staff complete department orientation including review of Tenet Case Management and Compliance policies and Documentation training
· Assists the Director of Case Management in the management of the department, but not limited to, hiring/training/managing staff, schedule coordination, analysis and reporting, interfacing, collaborating and working closely with the other departments
· Monitors case management processes and staff productivity to ensure medical necessity reviews are completed timely and accurately, payer communications are sent and authorizations or denials documented and followed up, and that transition planning assessments are completed timely.
(30% daily, essential)
Utilization Management
§ Monitors the review process to ensure medical necessity patients to be in the appropriate status and level of care per Tenet policy
§ Oversees submission of cases to Physician Advisor to ensure timely referral, follow up and documentation
§ Monitors the timely communication clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services
· Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
· Participates in Revenue Cycle meeting, researching disputes, uncovering patterns/trends and educating hospital and medical staff on actionable items
· Implements and monitors physician “peer to peer” review process with payers to resolve denials or downgrades concurrently
· Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
· Utilizes Crimson data to provide timely and meaningful information to the Utilization Management Committee and physician staff for performance improvement.
· Assists the Director in monitoring to ensure that CMS Follow-up Important Message (IM) and HINN letters are delivered and documented per federal regulations and Tenet policy.
§ Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
· Identifies and documents Avoidable Days using the data to address opportunities for improvement
· Prevents denials and disputes by communicating with payers and documenting relevant information
· Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements.
(20% daily, essential)
Transition Management
Implements and monitors process to ensure that a transition plan assessment is completed within 24 hours of patient admission to identify and document the anticipated transition plan for patients
· Ensures case management staff use electronic referral request process for patient placements
· Monitors to ensure that patient preference & choice is documented per CMS regulations and Tenet policy
· Monitors to ensure case management staff document in the Tenet Case Management documentation system to communicating information through clear, complete and concise documentation
· Ensures compliance that Case Management Staff are completing comprehensive assessments within 24 hours of patient admission to identify and document the anticipated transition plan for patients
· Integrates key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan
· Identifies patients at risk for readmission and applies appropriate intervention including risk assessment and referral to Social Work and/or Complex Case Review
· May delegate the implementation of the transition plan to LVN/LPN or Assistant staff and follows up to ensure the transition plan is completed timely and accurately
· Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers
· Ensures all Final Discharge Disposition Form are completed for Medicare beneficiaries per Tenet policy
· Accountable to identify and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Tenet Case Management documentation system to communicating information through clear, complete and concise documentation
(20% daily, essential)
Care Coordination
· Assists the Director in working with Nursing and hospital leadership to ensure Patient Care Conferences and Complex Case Review processes are in place to promote timely and appropriate throughput
· May participates in daily bed management meeting to support timely and effective patient placement and transfer within the hospital
· Monitors to ensures that patients have a plan of care that is clinically appropriate, consistent with patient preference & choice and available resources
· Monitors to ensures consults, testing and procedures are sequenced to support clinical needs with timely and efficient care delivery
· Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
· Effectively collaborates with physicians, nurses, ancillary staff, payers, patients and families to achieve optimum clinical outcomes
· Ensures the plan of care is clinically appropriate, consistent with patient preference & choice and available resources
(10% daily, essential)
Education
· Ensures and provides education to patients, physicians and the healthcare team relevant to the
o Effective progression of care,
o Appropriate level of care, and
o Safe and timely patient transition
· Provides patient and healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
· Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge
· Provides in-service education to Case Management Department on community resources
· As team leader of discharge planning unit provides guidance and monitoring of activities of discharge planning unit
(10% daily, essential)
Compliance
· Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
· Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
· Operates within the RN scope of practice as defined by state licensing regulations
· Remains current with Tenet Case Management practices
(10% daily, essential)
PERFORMANCE METRICS AND EVALUATION
The metrics below provide an indication of the effectiveness of the individual in this role and may be used for evaluative purposes. The list below is not meant to be exhaustive; other relevant metrics may exist.
· InterQual reviews completed accurately and timely
· Observation length of stay
· Excess Days/ALOS
· Clinical disputes - incidence and dollars
· Clinical Reviews & Authorizations
· Avoidable days
· Resource Utilization
· Position documentation and productivity
SUPERVISORY RESPONSIBILITIES:
Oversees staff assigned to Case Management Department, including, but not limited to, RN and LVN/LPN Case Managers, Social Workers, Case Manager Assistants, Authorization coordinators, and Discharge Planners.
Qualifications
Education and Experience:
Required: · Graduate of an accredited school of nursing. · 2 years of acute hospital case management or healthcare experience. · RN. Must be currently licensed, certified or registered to practice profession as required by law or regulation in state of practice or policy. Active RN license for state(s) covered. · Required skills include demonstrated organizational skills, excellent verbal and written communication skills, ability to lead and coordinate activities of a diverse group of people in a fast paced environment, critical thinking and problem solving skills and computer literacy. The hospital, in its sole discretion, reserves the right to combine any of the above required experiences, or to consider applicants other work related experience in order to meet the above mentioned requirements. Preferred: · Academic degree in nursing (bachelor's or master's). · 5 years of acute hospital case manage Accredited Case Manager (ACM)
Mandatory Requirements:
Hospital Mandatory Education Requirements: Orientation, Environment of Care, OSHA, Infection control, Abuse/Neglect, Ethics, etc.
Tuberculosis Screening
Fit Mask Testing
Licensure Renewal
End of Life Education
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