I. Job Summary

Assists the Director of Case Management in establishing a collaborative, interdisciplinary approach to Case Management that involves physician, clinical, financial and administrative staff. Professional Nurse leader who is responsible for the coordination of care for a designated group of patients through the entire continuum of care: pre-acute> acute? Post discharge phases. The Case Manager is responsible for insuring and facilitating the achievement of quality and cost outcomes; working with physicians in negotiating and procuring appropriate resources as deemed necessary; intervening at key points for individual patients to effectively manage length of stay and resources; partnering with the Nurse Manager and staff nurse in coordinating the services of the multiple disciplines; monitors patient care and services and document variances as necessary.

Employee authorization for access to EPHI is determined by job function and is under the direction of his/her Department Director or Nurse Manager.

II. Duties And Responsibilities

Employee will be required to readily available to work during any weather related incidents or other natural disasters and/or any emergency situation that may arise.

Position Responsibilities

• Coordinates care management process from patients entry into healthcare system to post-discharge, including outpatient settings.
• Assists in initiating and monitoring patient plan of care with the patient care team.
• Coordinates care and resources with physicians and other team members to achieve optimal patient outcomes by providing leadership and guidance to the care team in individualizing the plan of care team, and the interdisciplinary care team to assure appropriate, safe, cost-effective, timely and efficient care.
• Reviews all observation admissions regardless of payor source to determine appropriateness of stay as observation or change to inpatient admission.
• Interviews patients and families to identify needs and arranges for, but not limited to, medical, psychological, financial, environmental, and discharge planning.
• Serves as an advocate on behalf of patients and families.
• Communicates and negotiates with third party payors to obtain necessary pre-certification as well as approved days for inpatient stay.
• Communicates utilization assessments needed to justify level of care provided on concurrent basis.
• Assesses the appropriateness of the level of care and diagnostic time frames to determine suitability of level of care in accordance with established criteria.
• Maintains a roster of all community resources in and around our community, such as nursing home, DME companies, Hospice, home health, and home infusion, and makes it available to patients and families.
• Completes DMA6 and Level 1 on all patients requiring nursing home placement.
• Ensures smooth transition on all patients that are transferred from acute care to long term care and sends appropriate paperwork to facilities accepting patient.
• Maintains a professional relationship and communication with all members of the medical staff.
• Identifies actual and potential delays in service request or treatment and communicates them to the health care team so steps can be taken to eliminate or minimize delays.
• Works with case management staff and physician advisor to establish measurable goals and promote cost-­effective, high quality outcomes.

III. Education

• BSN preferred
• Current nursing license in the state of Georgia
• Experience in Utilization Management, Discharge planning, Case Management and Critical Paths highly desirable
• Requires a minimal of 3 years clinical nursing experience
• Effective communication, teaching and inter-personal skills

IV. Qualifications And Experience

Works collaboratively with interdisciplinary staff internal and external to the organization. Participates in quality improvement and evaluation processes related to the management of patient care. The Case Manager is on-site and available seven days a week, as well as holidays and, therefore, is required to work a weekend rotation and an occasional holiday.

V. Acknowledgment

This is not necessarily an exhaustive list of all responsibilities, skills, duties, requirements, efforts, or working conditions associated with the job. While this is intended to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks be performed when circumstances change ( e.g., emergencies, changes in personnel, workload, rush job, or technological developments).