JOB SUMMARY

The RN - Care Manager is a health care professional with experience and background to assure compliance with CMS Conditions of Participation regarding Utilization Review and Discharge Planning. The RN – Care Manager will lead an assessment to identify the patient's clinical needs to be accommodated and constructs a care plan to include DME, home health, Hospice, skilled nursing, anti-biotic regime, etc. The RN – Care Manager follows the hospital's Case Management/Utilization Plan that integrates the functions of utilization review, discharge planning, and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated resources to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes.
 
The RN – Care Manager evaluates patient's care delivery process while in the hospital, as well as performs denial management either during admission or post discharge. The RN – Care Manager acts as a resource to the interdisciplinary team providing clinical expertise in the areas of utilization review, status determination, clinical resource utilization, the discharge planning and appeal/denial management. The RN – Care Manager serves as the organizational consultant to providers and staff to optimize patient throughput and assure that the organization and the patient's care are managed in the most efficient manner possible and a collaborative practice to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes.

The RN – Care Manager communicates with the patient, family and the interdisciplinary health care team using the nursing process to assess, plan, implement, monitor, and evaluate options and services required to meet a patient’s physical, emotional, and social health needs in preparation for post hospital discharge.

*Much of the care coordination process is done via electronic communication. The RN – Care Manager is expected to check their WhidbeyHealth email at minimum 3 times a day and utilize TEAMS messaging.

                                                                                                                                                                                                                       

PRINCIPLE FUNCTIONS includes the following, other duties may be assigned:

Acts as an interdisciplinary team member within the Transitions Department. Performs pre-admission status recommendation review for multiple care settings as assigned (i.e., Emergency Department, Direct Admission/Transfer, and/or elective procedure), to communicate with providers status guidance based on available information. Completes an initial needs assessment when a patient is admitted, in observation status or any other time deemed necessary by the interdisciplinary team. Completes rehospitalization assessment for readmissions. Works closely with the care team to navigate the individualized care plan through in-hospital stay to discharge: When the patient and or family has specific adjustment or psych/social needs, the social worker is integrated into the care plan to a large degree. Social Work will also assist CMRN with placement of patients into prescribed facility care. May contact providers, programs, and or agencies to who the patient has been referred to verify adherence to the discharge plan; follow up may be indicated for patients who have been identified as high risk for re-hospitalization or non-compliance with recommended follow up care. Facilitates multidisciplinary treatment planning rounds and documents changes accordingly. Attempts to contact discharged patients within 24 hours of discharge for follow-up. Ensures appropriate patient status upon admission and manages patient status conversions, as appropriate by contacting the provider or addressing issues with other departments as needed. Ensures completion of admission medical necessity reviews within 24 hours of admission. Completes concurrent inpatient medical necessity reviews daily, unless otherwise specified by payer. Completes Observation medical necessity reviews at a minimum of every 12 hours (twice daily). Completes Medicare extended stay reviews, as appropriate. Identifies and escalates all 1MN and 2MN Medicare IP stays. Collaborates with Transitions of Care Management team, as appropriate (i.e., extended observation stays, patients no longer meeting medical necessity, status changes). Collaborates with physicians, as appropriate (i.e., to address issues concerning medical necessity, status orders, appropriate level of care, peer-to-peer involvement, etc.). Collaborates with payers, as appropriate (i.e., discuss status, changes in length of stay, changes in pre-authorizations warranting reauthorization, etc.). Communicates and collaborates with Patient Access, Patient Financial Services (PFS) and Health Information Management (HIM), as appropriate. Escalates Medical Necessity (patient status / level of care) concerns and other utilization mangement concerns to Physician Advisor or designated leader, as appropriate. Assists with discharge appeal process, as appropriate. Provides timely and continual coverage of assigned work area to ensure all accounts are complete. Assists in the identification of Avoidable Days and communicates information to executive director of nursing as well as other leadership, as appropriate. Communicates with providers directly to notify of appropriate status. Obtains and transcribes telephone orders to change patient status in accordance with WhidbeyHealth policies, as well as monitors for authorization by the physician. Complies with all documentation requirements. Follows up on action items prior to the end of shift. Maintains a working knowledge of payer contracts and regulatory requirements and UM specific changes (i.e., changes in authorizations, payer contracts, CMS, regulatory requirements). Completes all tasks within department guidelines. Completes appropriate handoff on all outstanding items and communicates to oncoming care manager, social worker, transitions assistant or leadership as appropriate. Adheres to the policies, procedures, rules, regulations, and laws of the hospital and federal and state governing bodies. Provides support regarding Medicare documentation requirements. Participates in the delivery of regulatory forms to patients when appropriate. Communicates with insurance companies regarding the medical necessity of the admission and provides clinical documentation and reviews to insurance companies as requested for purposes of ongoing authorization of hospital stays. Actively participates in clinical performance improvement activities and utilization review committee. Assists in the collection and reporting of resource and financial indicators including LOS, cost per case, avoidable days, resource utilization, readmission rates, concurrent denials, and appeals. Supports the vision, mission, and values of the organization in all respects. Supports Value Improvement Practice principles of continuous improvement with energy and enthusiasm, functioning as a champion of change. Provides and maintains a safe environment for caregivers, patients, and guests. Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings. Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate. May perform additional duties of similar complexity within the organization, as required or assigned.

JOB KNOWLEDGE & QUALIFICATIONS

Education

Graduate of an accredited school of nursing.  BSN preferred.                                                                                                                                                                                                                                                                                                 

Training and Experience

Minimum of 3 years of current experience as an RN Minimum of two years current experience as an RN in utilization review, case management and/or discharge planning in a hospital inpatient acute care unit, health plan or a combination of both. Experience using MCG or InterQual Criteria to determine appropriate level of care preferred. Experience using clinical documentation to make recommendations regarding the most appropriate route of payment resolution, up to and including writing appeal letters.  Ability to construct and document a succinct, assertive, and fact-based clinical summary to support medical necessary criteria.

 

Certificates, Licenses, Registrations

Washington State DOH RN License required. Current BLS HCP required. Certified Case Manager (CCM) or Accredited Case Manager (ACM) preferred.   Benefit Information and Wage Transparancy:  WhidbeyHealth Employees who work a 0.5 FTE or higher are categorized as, “benefit eligible”.

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Wage Range: $37.450 - $70.012