JOB DESCRIPTION: Responsible for coordinating clinically complex patients' care across a continuum; ensuring and facilitating the achievement of quality clinical and cost outcomes; negotiating, procuring and coordinating appropriate services and resources needed by the patients; and at key points, intervening to address and resolve barriers to timely and efficient care delivery and reimbursement. Communicates confidently and effectively with all levels of hospital staff, physicians and payors; Is assertive without being overly aggressive; Conveys an impression which reflects favorably upon the public relations of the organization. Reinforces and ensures appropriate patient education is carried out according to plan across the continuum; Provides ongoing educational opportunities to enhance health care teams knowledge of case management services; Participates in and facilitates patient/family education and communication; Serves as an internal resource regarding reimbursement and clinical practice issues; Serves as a coach, mentor and role model to all professional staff. Case facilitation including: Assesses patient clinical level of care and needs to assure that the patient is in the correct admission status; Documents all assessments and interventions per Department policy in Allscripts; Evaluates appropriate clinical interventions in collaboration with all health care team members to ensure standards of care are met; Initiates referrals as indicated to the appropriate health care team member; Need for social worker intervention; Communicates patient clinical and disposition needs for patients transferred to another level of care; Assists to identify and resolve operational barriers to the progression of care. Applies approved utilization acuity criteria (Interqual or MCG Guidelines) to monitor appropriateness of admissions and continued stays for assigned patient case load; to include admission reviews within 24 hours or first business day following admission, daily review of medical necessity for all inpatients, concurrent stay documentation per utilization management plan, verification and correction of patient status, Monitoring of observation patients per hospital policy; Maintains documentation of utilization review function per hospital policy and federal and state requirements; Identifies need for EHR Physician Reviewer intervention and facilitates same per departmental referral process; Completes HINN and Code 44, processes as departmental policy; Provide payer specialists with clinical information to assist with third party payor interventions to ensure authorization for services is obtained; Maintains working knowledge of and compliance with commercial/ Medicare/ Medicaid payor guidelines. Assess patients for discharge needs and coordinates discharge plans and develops and maintains referral network to ensure complete and expeditious movement across the care continuum. Facilitates completion of discharge disposition paperwork. Effectively matches resources available to patient needs. Effecient and effective access of community resources to meet patient needs. Collaborates and communicates with multidiscplinary team throughout all phases of the discharge planning process. This includes participation in care planning unit conferences in assigned area. Informs patient/family and reviews clinical discharge planning options and plans with physician when appropriate. Collaborates/communicates with external case managers. Initiates and facilitates referrals for home health care, hospice, medical equipment and supplies, and returns to skilled nursing facilities (SNF).
MINIMUM QUALIFICATIONS: Minimum of three years varied hospital experience or comparable job related experience. Three to five years of recent acute hospital experience, three to five years of discharge planning experience, preferred. Graduate of an accredited school of nursing. ACM or CCM certification required within one year of eligibility. BS in Nursing or health related field hospital / case management/ discharge planning, preferred. All nurses employed in roles requiring an unencumbered nursing license must have a valid, active license or temporary permit approved by the Georgia Licensing Board. BLS certification required.