Registered Nurse Case Manager

POSITION PURPOSE 

The Case Manager coordinates care across an episode and/or the continuum for clients with complex problems and diverse needs.  The Case Manager’s focus is to maintain patients at an optimal level of health and to support self-care.  Case Managers collaborate with physicians, social services, nurses, and community agencies to define care options and resources, to plan cost effective quality care and to achieve optimal outcomes. 

Specific responsibilities include case screening, insurance approval, assurance of timely services, and facilitation of discharge with transition to the appropriate services.  Patient outcomes are achieved through effective application of care plans, managed care concepts, appropriateness criteria, resource management, knowledge of community resources, and collaboration with other clinical disciplines.  Works proactively to coordinate the services of physicians, nurses, and other disciplines to effectively prepare patients for discharge.  The Case Manager facilitates program development, efficient care delivery processes and quality improvement including tracking of resource utilization and outcome measures.  The Case Manager is accountable for improving service using cost and quality outcome data, current clinical practices and related research, regulatory requirements and comparative benchmark opportunities.   

Customers include patients, families/visitors, physicians, physician assistants, nurse practitioners, case managers, representatives of third-party payers, representatives of referring agencies, interdepartmental and intradepartmental staff, vendors, and volunteers.     

ESSENTIAL FUNCTIONS 

Actively knows, understands, incorporates, and demonstrates the organization’s mission and core values, including the Guiding Behaviors and Caring Model Principles, and always conducts oneself in a manner consistent with these values.  

Maintains a working knowledge of applicable Federal, State and local laws and regulations, Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures to ensure adherence in a manner that reflects honest, ethical and professional behavior. 

• Demonstrates knowledge, skills and abilities to provide case management services appropriate to the age of patients served. 

• Exhibits sound judgment, critical thinking, problem solving and decision-making skills. 

• Communicates effectively with patients, significant others, and members of the health care team.  

• Compiles information; keeps records, prepares or directs preparation of reports and correspondence. 

• Executes daily utilization functions for assigned patients, including prior authorization, admission, precertification/certification/recertification, concurrent and retrospective review, associated analysis, and referral appropriateness.  

• Participates in comprehensive team meetings and conferences regarding specific patient needs that affect cost, quality, and length of stay.  Demonstrates ability to promote collaboration and creativity among members of the health care team. 

• Responsible for assuring thorough case management assessment, as well as early and ongoing discharge plans by collaborating with patients, families, physician, payors, and providers across the continuum of care.   

• Reports potential catastrophic and high-cost cases to department director, nursing director, and finance department for appropriate medical/administrative review and management. 

• Effectively manages length of stay and cost avoidance.   

• Discuss cases with Utilization Review Committee and/or Executive Health Resources (EHR) when cases fail to meet admission, treatment, and length of stay and/or discharge standards.  

• Attends meetings of the Utilization Review Committee and submits reports as required.  Participates in the development of a written plan that describes the Utilization Review Program. 

• Applies quality improvement methods and techniques to improve case management processes to maximize cost and quality benefits for MercyOne Medical Center.  

• Performs other duties consistent with the purpose of the job as directed. 

• Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.