The Case Manager is accountable for the organization, and resources that are necessary and appropriate for the achievement of patient outcomes within effective time frames. In addition, the Case Manager will coordinate the plan of care among all members of the health care team. Must have ability to practice under minimal supervision to perform the following four essential activities of Case Management: Assessment, Planning, Implementation and Coordination. The Case Manager must assist to reduce practice variations, and enhance patient outcomes.
Complete the assessment process to identify individual needs and develop a comprehensive case management plan. Information will be gathered from, but not limited to: patient, family, professional and non-professional care givers, employers and/or health records.
Ongoing monitoring of information relevant to the case management plan. Concurrent reviews are conducted every 1-3 days for ongoing intensity of service, appropriateness of setting and discharge planning.
Ongoing evaluation of the case management plan's effectiveness including reassessment for any significant decline in status and subsequent new planning required prior to discharge.
Complete the planning process to determine specific objectives, goals, and actions designed to meet the patient's needs.
Implementation of the Case Manager's plan will occur in a timely manner to facilitate accomplishment of the plan objective and goals involving the Physician Advisor as necessary.
Coordination and integration of resources necessary to accomplish the goal of the case management plan with the patient as well as facilitate Interdisciplinary Team Meetings (ITMs).
Maintain a ready and current working knowledge base on our top five payor sources, reimbursement structure, network provider list, approval criteria, and appeals process.
The Case Manager will conduct all negotiations for approval/authorization of services and be accountable to conduct/facilitate with the Physician and/or Physician Advisor all appeals or denials received. The Case Manager will establish a professional and productive working relationship with payer source case managers.
Complete work within acceptable time frame.
Demonstrate the ability to perform work in an accurate and timely manner in periods of increased work load and stress.
Demonstrate good judgment in handling situations not covered by written or verbal instructions.
Demonstrate a thorough knowledge of work practices, emergency procedures, and personal protective equipment (PPE).
To be knowledgeable and be able to complete CDI on all inpatient charts.
Interact with all members of the health care team, act as a consultant to other personnel and function as a liaison among patient, family, and other health care staff throughout the continuum of care.
Monitor Resource Management protocols and monitors avoidable days.
Ensure the process of identification and reporting of nosocomial infections and report to the Infection Control Coordinator.
Continually strive to make productive use of time through careful coordination of department tasks, setting priorities, and reducing non-essential interruptions in order to be responsive to the needs of the department and the Medical Center.
Ability to use planning, research, foresight, and facility goals and needs to analyze situations and make decisions without a delay while involving all appropriate parties.
Promote and continually educate employees on the concept of excellent customer service for all customers of the department, particularly patients, visitor's, physicians, and other employees.
Consult supervisor for additional assignments, or independently assume responsibility for unassigned tasks.
Participate in Quality Improvement activities as needed to continually improve the department's performance.
Regularly and routinely provide suggestions to customers, suppliers and teams working on processes to identify innovations and ideas for improvement.
Accept and act upon constructive criticism.
Exhibit willingness to adjust personal schedule in case of workload fluctuations or other departmental needs.
Channel concerns appropriately.
Foster a sense of teamwork and collaboration within department and Medical Center.
Be an active participant in department meetings by providing positive suggestions and input.
Assume responsibility for on-going professional development.
1. Complies with local, state, and federal laws and regulations.
Education, Skills, Experience Requirements:
Registered nurse must be a graduate of an approved School of Nursing and hold a current, valid license in the State of Maine.
Two to three years' experience as a registered nurse.
Three to five years' experience in an acute care hospital setting with at least two years of med/surg. experience.
Recognition of quality of care and risk issues and report appropriate individual.
Assessment of age-specific data in terms of patient needs
Working knowledge of criteria used to assess levels of care.
Obtain necessary annual CEU's.
Maintains current BLS certification.