Case Manager is responsible for chart review to evaluate medical necessity for admission, continued stay, and the appropriate level of care. Monitors the care of assigned patients to assure quality cost effective utilization of resources and optimal outcomes. Responsible for coordinating the patient's plan of care from admission to discharge and or transfer to another level of care.

PRINCIPAL DUTIES AND RESPONSIBILITIES (*Essential Functions)

1. Applies to individual case, through chart review, third payer regulations that govern admissions, continued stay, and discharge, i.e. IS/SI.
2. Collects data related to clinical improvement initiatives for the purpose of developing action plans.
3. Conducts concurrent chart reviews to assure complete and accurate medical records documentation.
4. Coordinates the patient's plan of care with all members of the health care team including the patient, caregiver, and or family members and case management.
5. Demonstrates proficiency in patient assessment and documentation.
6. Interviews and assesses patients to determine potential barriers to timely discharge/transfer to another level of care.
7. Provides all payers with accurate, updated information.
8. Obtains covered stay certification and prior authorization as appropriate.
9. Refers cases when appropriate to physician advisor for medical necessity, continued stay, physician education and appropriate level of care.
10. Refers to Social Services when appropriate.
11. Ensures discharge planning to the appropriate level of care, sub-acute, hospital units, and outpatient services.
12. Supports hospital CQI programs by participation on relevant teams.
13. Performs other duties as needed and/or assigned.

JOB SPECIFICATIONS (Minimum Requirements)

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of appropriate and timely return transition levels of care.
• Knowledge of CARF, Regulatory Agencies and State Board of Health, Long Term Care, Acute Care and Ambulatory Care Standards.
• Demonstrates excellent interpersonal and problem-solving skills.
• Demonstrates self-directed, goal orientated and customer service.
• Excellent organizational and prioritization skills to meet deadlines.
• Capable of functioning effectively across service lines.
• Ability to assess and interpret data about the patients status in order to identify each patients age, specific needs and provide the care needed by the infant, child, adolescent, young adult, middle adult and geriatric patient.
• Ability to independently perform comprehensive chart review with subsequent abstraction or relevant information including interpretation of lab results, EKG and other medical tests.
• Ability to communicate effectively both verbally and in writing.
• Ability to provide compassionate patient care orientated with an effort for timeliness and accuracy in the delivery of service.
• Ability to respond positively to the needs of patients and family. Addresses customer concerns in a private, respectful and calm manner.

EDUCATION

All post high school education must have been obtained from a recognized College or University.  

• Associates Nursing Required
• Bachelors Nursing Preferred

EXPERIENCE

• 3 years Acute Care experience Required

LICENSE/CERTIFICATION

• Active Licensed Registered Nurse
• Basic Life Support Certification

STANDARDS OF BEHAVIOR
Meets the Standards of Behavior as outlined in Personnel Policy and Procedure #1, Employee Relations Code.

CONFIDENTIALITY/HIPAA/CORPORATE COMPLIANCE
Demonstrates knowledge of procedures for protecting and maintaining security, confidentiality and integrity of employee, patient, family, organizational and other medical information. Understands and supports the commitment of Methodist Hospitals in adhering to federal, state and local laws, rules and regulations governing ethical business practices for healthcare providers.

DISCLAIMER - The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. The statements are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required.