Case Management-RN-1834

Essential Values-Based, Leadership and Management Competencies:

Demonstrates competencies in line with the five core values that are the foundation of all activities performed by employees in order to achieve the Mission of Artesia General Hospital

• Servant Leadership – Leading by serving others with compassion and humility.

• Excellence – Striving for the highest quality in all we do.

• Respect – Treating everyone with dignity and kindness

.• Virtuousness – Acting with honesty, integrity, and accountability.

• Innovation – Embracing new ideas to improve care and outcomes.

• Community – Fostering collaboration to meet the needs of those we serve.

• Education – Promoting learning and professional development.

ESSENTIAL FUNCTIONS:

· Directs the daily operations of case management, utilization management, discharge planning, social services, and care transitions.

· Establishes department goals, workflows, performance expectations, and accountability measures.

· Provides supervision, coaching, education, and performance evaluation for case management and social services staff.

· Ensures adequate coverage for utilization review, discharge planning, payer communication, and high- risk patient needs.

• Determines Patient medical eligibility, qualifying diagnosis, and determines Medicare/Managed Care eligibility based on skilled services provided

· Develops, reviews, and maintains departmental policies and procedures.

· Promotes effective communication and collaboration among case management staff, nursing, physicians, ancillary departments, and hospital leadership.

· Assists with departmental budgeting, staffing, productivity, and resource allocation.

• • Identifies and plans strategies to reduce in-patient length of stay and resource consumption.
  • Provides patient/ family with information about home health care, skilled nursing facilities, rehabilitation facilities and appropriate providers.
  • Maintains availability to the patient/family as a resource to facilitate communication among providers and to monitor services rendered.

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UTILIZATION MANAGEMENT and MCG

• Oversees the consistent and appropriate application of MCG guidelines for admission, level-of-care, continued-stay, and discharge-readiness reviews.
• Ensures MCG criteria are used as a clinical decision-support tool and not as a substitute for physician judgment, applicable regulations, payer requirements, or the patient’s individual clinical circumstances.
• Reviews inpatient, observation, and outpatient cases to support appropriate patient-status recommendations.
• Ensures timely initial and concurrent reviews, payer notifications, authorizations, and clinical updates.
• Escalates cases that do not clearly meet MCG criteria or require additional physician documentation.
• Collaborates with attending physicians and hospital leadership regarding inpatient versus observation status.
• Facilitates secondary physician review or physician-advisor review when medical necessity or patient status remains unclear.
• Supports compliance with the Medicare Two-Midnight Rule and other applicable CMS patient-status requirements.
• Ensures required Medicare notices are delivered accurately and timely, including the Medicare Outpatient Observation Notice and other applicable beneficiary notices.
• Monitors the use of MCG and identifies educational needs, inconsistent application, and workflow gaps.
• Maintains staff competency in the hospital’s current licensed MCG content and documentation requirements.

PATIENT STATUS and MEDICAL NECESSITY

• Reviews admissions and continued stays for medical necessity, intensity of service, severity of illness, and appropriate level of care.
• Identifies cases at risk for incorrect status, noncoverage, delayed authorization, or denial.
• Communicates medical-necessity concerns promptly to physicians and appropriate hospital leaders.
• Facilitates status changes when supported by the patient’s clinical condition, physician order, regulatory requirements, and hospital policy.
• Monitors short inpatient stays, extended observation stays, avoidable admissions, and potentially preventable readmissions.
• Ensures that patient-status determinations and changes are properly documented and supported in the medical record.
• Collaborates with health information management, clinical documentation integrity, patient financial services, and revenue-cycle staff to improve documentation and reimbursement integrity.

DISCHARGE PLANNING and CARE COORDINATION

• Ensures discharge planning begins at admission and is reassessed throughout the hospitalization.
• Oversees the completion of initial assessments and the identification of medical, psychosocial, financial, functional, behavioral, and post-acute care needs.
• Leads interdisciplinary efforts to develop safe, timely, and patient-centered discharge plans.
• Coordinates placement and services involving skilled nursing facilities, rehabilitation facilities, long-term acute-care hospitals, home health, hospice, durable medical equipment, behavioral health, transportation, and community resources.
• Ensures patients and families are actively involved in discharge planning and receive understandable information regarding available options.
• Addresses barriers that delay discharge, including placement, transportation, medication access, insurance authorization, housing, caregiver availability, and equipment needs.
• Facilitates complex case conferences and multidisciplinary care-planning meetings.
• Supports safe transitions of care and communication with post-acute providers and primary-care clinicians.
• Works to reduce avoidable readmissions and prevent gaps in care following discharge.

LENGTH of STAY and THROUGHPUT

• Participates in or leads daily interdisciplinary patient progression and discharge-planning rounds.
• Reviews each patient’s expected date of discharge, barriers to progression, outstanding tests or consultations, and post-acute needs.
• Identifies avoidable delays and escalates unresolved barriers to the appropriate leader or physician.
• Collaborates with nursing, medical staff, ancillary departments, and hospital leadership to improve patient flow.
• Monitors observation length of stay, inpatient length of stay, avoidable days, discharge order-to-departure time, and delayed discharges.
• Develops corrective action plans when performance does not meet organizational goals.

DENIAL PREVENTION and MANAGEMENT

• Oversees the identification, tracking, review, and response to clinical and medical-necessity denials.
• Ensures payer requests for clinical information are completed accurately and within required time frames.
• Coordinates peer-to-peer reviews, reconsiderations, and appeals with physicians, payers, and revenue-cycle staff.
• Performs root-cause analysis of denials and develops strategies to prevent recurrence.
• Educates physicians and staff regarding documentation patterns that contribute to denials or payment risk.
• Tracks denial trends by payer, reason, provider, service line, patient status, and financial impact.
• Collaborates with finance and revenue-cycle leadership to improve authorization processes and reduce preventable write-offs.

REGULATORY and ACCREDITATION COMPLIANCE

• Maintains compliance with applicable CMS Conditions of Participation, Medicare requirements, state and federal regulations, hospital policies, and accreditation standards.
• Supports compliance with patient-choice, discharge-planning, beneficiary-notification, and utilization-review requirements.
• Participates in the hospital’s Utilization Review Committee and prepares required utilization data and case reviews.
• Maintains confidentiality and complies with HIPAA and other patient-privacy requirements.
• Ensures department records, case reviews, notices, and supporting documentation are complete and audit-ready.
• Participates in regulatory surveys, payer audits, internal audits, and corrective-action planning.
• Maintains current knowledge of changes in reimbursement, utilization management, discharge planning, and payer requirements.

QUALITY and PERFORMANCE IMPROVEMENT

• Develops and monitors department performance indicators, including:
  • Inpatient and observation conversion trends
  • Observation stays exceeding established targets
  • Initial and concurrent review timeliness
  • Authorization completion
  • Inpatient and observation length of stay
  • Avoidable days and discharge delays
  • Readmissions
  • Medical-necessity and authorization denials
  • Appeal outcomes
  • Discharges before noon or other established throughput goals
  • Referral and placement turnaround times
  • MCG review compliance
  • Medicare-notice compliance

• Reports performance trends, risks, and corrective actions to hospital leadership and applicable committees.
• Uses case reviews and data analysis to identify opportunities for improved quality, efficiency, documentation, and financial performance.
• Leads performance-improvement initiatives related to utilization, care transitions, patient flow, and denial prevention.

MEDICAL STAFF COLLABORATION

• Develops effective working relationships with attending physicians, emergency department providers, hospitalists, surgeons, and other medical staff members.
• Provides education regarding MCG, patient status, medical necessity, documentation, length of stay, and payer requirements.
• Communicates physician-specific trends respectfully and objectively.
• Escalates unresolved concerns through the established chain of command.
• Supports physician-to-physician discussions and peer-to-peer reviews when required.
• Serves as a resource to the medical staff regarding utilization-management and discharge-planning requirements.

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ADDITIONAL RESPONSIBILITIES:

• • As assigned.

REQUIRED QUALIFICATIONS:

• Bachelor’s degree in nursing required.
• Current, unrestricted Registered Nurse license in the state of New Mexico or eligibility for licensure.
• Minimum of five years of clinical nursing experience in an acute-care setting.
• Minimum of three years of case management, utilization review, discharge planning, or related experience.
• Minimum of two years of leadership or supervisory experience preferred.
• Demonstrated experience using MCG or comparable evidence-based utilization-management criteria.
• Knowledge of inpatient, observation, and outpatient status requirements.
• Knowledge of CMS regulations, the Medicare Two-Midnight Rule, utilization-review requirements, discharge-planning requirements, and beneficiary notices.
• Experience with payer authorization, concurrent review, denials, appeals, and peer-to-peer processes.
• Proficiency with electronic health records, utilization-review systems, data analysis, and Microsoft Office applications.

KNOWLEDGE, SKILLS and ABILITIES:

• Strong working knowledge of MCG guidelines and utilization-management principles.
• Ability to interpret clinical information and communicate medical-necessity concerns clearly.
• Strong leadership, coaching, and performance-management skills.
• Ability to build collaborative relationships with physicians and interdisciplinary teams.
• Excellent critical-thinking, problem-solving, organizational, and prioritization skills.
• Ability to manage multiple complex cases and operational priorities in a small-hospital environment.
• Understanding of reimbursement, payer contracts, authorization requirements, and denial risk.
• Ability to analyze performance data and translate findings into measurable improvement plans.
• Strong verbal, written, and presentation skills.
• Ability to manage sensitive situations professionally and maintain patient confidentiality.
• Commitment to patient-centered care, regulatory compliance, ethical practice, and responsible resource utilization.

PERFORMANCE EXPECTATIONS:

The Director of Case Management will be expected to:

• Establish a reliable daily utilization-review and discharge-planning process.
• Ensure all admissions receive timely medical-necessity and patient-status review.
• Improve the accuracy of inpatient and observation status determinations.
• Reduce extended observation stays and avoidable inpatient days.
• Improve physician documentation supporting medical necessity.
• Strengthen the consistent use of MCG across the organization.
• Reduce preventable clinical and authorization denials.
• Improve discharge planning, care transitions, and interdisciplinary communication.
• Maintain department readiness for regulatory, accreditation, and payer audits.
• Provide hospital leadership with accurate and actionable case-management performance data.

AGE-RELATED COMPETENCIES: Demonstrates the basic knowledge and skills necessary to identify age-specific patient needs appropriate for this position.

Information Management: Treats all information and data within the scope of the position with appropriate confidentiality and security.

Risk Management/Quality Management/Safety: Cooperates fully in all Risk Management, Quality Management, and Safety Activities and Investigations.

ENVIROMENTAL CONDITIONS: Work environment consists of daily patient contact, which may include exposure to blood, or other body fluids.