SUMMARY:

The individual in this position is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patient’s resources and right to self-determination.The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity and to assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions.This position integrates national standards for case management scope of services including:

• 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 appropriate level of care
• Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
• Education provided to physicians, patients, families and caregivers
• Precepts new staff members and acts as resource to all staff.
• Participates in department Quality improvement initiatives, one committee participation and/or major Projects as assigned

The individual’s responsibilities include the following activities: a) accurate medical necessity screening and submission for UR committee review, b) care coordination, c) transitionplanning assessment and reassessment, d) implementation or oversight of implementation of the transition plan, e) leading and facilitating multi-disciplinary patient care conferences, f) managing concurrent disputes, g) making appropriate referrals to other departments, h) communicating with patients and families about the plan of care, i) collaborating with physicians, office staff and ancillary departments, , j) assuring patient education is completed to support post-acute needs , k) timely complete and concise documentation in the Case Management documentation system, l ) maintenance of accurate patient demographic and insurance information, m) identification and documentation of potentially avoidable days, n) identification and reporting over and underutilization, o) and other duties as assigned.

This individual will work in collaboration with a discharge planner.

QUALIFICATIONS:

Required qualifications include an active Registered Nurse license with at least two years acute hospital patient care experience. BSN preferred Accredited Case Manager (ACM) or CCMpreferred. Acute hospital case management experience preferred. 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