Care Manager

Overview

The Care Manager is accountable for outcomes as related to providing coordination of patient management through the continuum of care. Responsible for financial, clinical, and discharge planning evaluation for each assigned patient. Assures payment for services rendered, coordinates care, manages resources, and facilitates each patient encounter for efficient and effective outcomes as related to quality, clinical and cost areas.

Responsibilities

• Manages an assigned caseload of patients from preadmission to discharge.
• Assumes responsibility for admission appropriateness (medical necessity), (outpatient, observation, inpatient admission), continued stay, and medical record monitoring.
• Coordinates communication with third party payers, external review agencies and the Utilization Committee.
• Identify managed care issues and address promptly as related to denials management.
• Coordinates and collaborate with physicians, provider, multidisciplinary team and other health care professionals concerning patient’s goals, plan of care and progress.
• Revise and adjust on a daily basis the plan of care to accommodate the needs of the individual patient based on continuing assessment of patient condition.
• Leads discharge planning multidisciplinary team meetings, ensures documentation of meetings.
• Advocate for the patient/family and is knowledgeable of and act in accordance with legal principles of consent, healthcare proxies (power of attorney for healthcare) and advance medical directives.
• Stays abreast of developments in the case management field and seeks ongoing education to enhance practice skills. Care Management is willing to seek certification in case management field if made available through ARH.
• Stays abreast of regulatory agency guidelines as pertains to area of practice
• Initiate and monitor clinical care guidelines and analyze positive and negative variances
• Ensure continuity of care through formulation of discharge plan on admission and follow though until patient is discharged.
• Ensure appropriate use of resources.
• Monitor patient care for appropriate use of resources.
• Monitors length of stay on a concurrent, weekly, and monthly basis. Ensures that length of stay is appropriate based on medical necessity. Works with medical staff, hospital staff, and others to overcome barriers to discharge.
• Monitors in-house denials for extended lengths of stay.
• Participates in the denials management process to help ensure establishment of and adherence to processes that will minimize denials by third-party payers.
• Participates as a member of the Utilization Committee
• Assists in the collection of data to trend and analyze outcomes for identification of improvement opportunities.
• Participates in data collection, specific to outcomes data.
• Assesses the appropriateness of the level of care; diagnostic testing and clinical procedures; quality and clinical risk issues; and documentation of medical record completeness.
• Performs other related duties as assigned.

Qualifications

Required Education

• Associate Degree in Nursing from an accredited school of nursing and current Registered Nurse (RN) licensure in the state of employment preferred.
• Bachelor of Science in Nursing (BSN) preferred and must be obtained within five (5) years of hire.

Preferred Experience

• Four (4) to six (6) years of nursing experience preferred.
• Five (5) years of nursing experience may be considered with demonstrated skills required for the position.

Required Skills, Knowledge, and Abilities

• Advanced problem-solving and decision-making skills.
• Strong multitasking abilities with the ability to manage competing priorities and deadlines; flexible and adaptable.
• Ability to interact tactfully and professionally with patients, families, staff, and community members.
• Advanced communication skills with the ability to lead and support a team.
• Advanced planning, execution, delivery, and operational support skills.
• Ability to evaluate the relative costs and benefits of potential actions and make sound decisions.
• Ability to function effectively in a clinical setting with diverse patient populations and healthcare teams.
• Mastery of care transition processes and available patient resources.
• Strong digital literacy and technology skills.
• Ability to handle sensitive and confidential information ethically and responsibly.

Licenses and Certifications

Required

• Licensed Practical Nurse (LPN) licensure.

Preferred

• Registered Nurse (RN) licensure.