Coordinates the integration of social services/case management functions into the patient care, discharge planning processes in collaboration with other hospital departments, external service organizations, agencies and healthcare facilities.
Performs initial case management assessment to determine care coordination and discharge planning needs. Conducts admission and concurrent medical record review using specific indicators and criteria in accordance with regulatory and contractual requirements as well as internal policy. Uses established medically necessity criteria as described by policy to conduct screening for appropriate-ness of admission (IP verses observation) and continued stay for intensity of service/severity of illness. Escalates cases as appropriate and per policy to Physician Advisor and Director. Collaborates with Bed Management to ensure appropriate bed placement based on level of care. Assimilates information obtained from information systems, service schedules, registration area, Bed Management, clinics, other facilities, and insurance companies to accurately assess patient clinical needs and treatment.
Acts as patient advocate by negotiating for, and coordinating resources with payers, agencies and vendors during inpatient and transition phases.
Identifies and communicates quality and risk issues to the appropriate staff/departments in a timely manner.
Acts as a resource and provides staff and physician education related to resource utilization, discharge planning and psychosocial aspects of healthcare delivery.
EDUCATION AND EXPERIENCE REQUIRED:
Associates Degree in Nursing
Minimum of two years’ recent acute care experience
Minimum of an additional two years’ experience in healthcare related fields
EDUCATION AND EXPERIENCE PREFERRED:
Master’s degree in Nursing
Minimum of two years of utilization review/case management experience and a minimum of one year of experience in discharge planning in an acute care setting highly desirable.
LICENSURE, CERTIFICATION, OR REGISTRATION REQUIRED:
LICENSURE, CERTIFICATION, OR REGISTRATION PREFERRED:
Case Management certification highly desirable – ACM (Accredited Case Manager), CCM (Certified Case Manager), RN-BC (Board Certified in Case Management)
Under general supervision of the Director and/or Manager of Case Management, in collaboration with the patient/family, social workers, physicians and interdisciplinary team, the RN Case Manager ensures patient progression through the continuum of care in an efficient and cost-effective manner. The RN case manager is responsible for identifying, initiating and managing optimal patient flow/throughput to enhance continuity of care, smooth and safe transitions, patient satisfaction, patient safety and length of stay management. Support and expertise are provided through comprehensive assessment, planning, implementation and overall evaluation of individual patient needs. Care coordination, utilization review and management, as well as discharge planning are accountabilities of this role. Education is provided to physicians and other members of the team on the issues related to utilization review including inappropriate admissions and placements. Payer-based requests regarding individual members are fulfilled, where appropriate and pertinent. The Case Manager adheres to departmental and organizational goals, objectives, standards of performance and policies and procedures, continually ensuring quality patient care and regulatory compliance. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.