Case Manager-ED

• Collaborates with Physicians, Nurses, Social Workers, and other hospital departments as necessary, to facilitate the improvement in the quality of care and/or the efficiency with which hospital services are utilized.
• Ensures the active involvement of the patient and or family in the evaluation process and provides assistance with planning and arranging post hospital services.
• Identifies appropriate community resources for each assigned patient and works collaboratively with patients, families, multidisciplinary team members and community agencies to achieve desired patient outcomes.
• Ensures initial implementation of the discharge plan and appropriate education regarding discharge plan to patient and family to facilitate a safe transition of care from the hospital to home or another facility.
• Performs Utilization Review (UR) to determine medical necessity for admission, continued stay, appropriate utilization of resources and level of care determination based upon MCG criteria.
• Communicates medical necessity information with the requesting Payers, as per KHI policies and procedures. In conjunction with the Discharge Care Coordinator, determines whether required post discharge services are covered by the patient’s payer and informs patient of coverage determinations.
• Maintains accurate and timely documentation of patient assessments, continuing reassessments and discharge plans.
• Participates in Multidisciplinary Rounds (MDR) to share information and facilitate the health care team in meeting the patient’s medical and psychosocial needs.
• Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to the mission and vision of Kingman Regional Medical Center.

Review Process:

• Conducts assessment and evaluation of admitted patients for medical, physical, and psychological factors that may contribute to their disease process and may require specific or complex continuing care and/or supportive services.
• Reviews medical records concurrently and retrospectively as necessary to assess the management of cases by comparing progress to predetermined criteria.
• Evaluates for medical necessity, level of care, coverage issues, appropriate utilization of resources, and planning by reviewing physician documentation to ensure that MCG criteria is met.
• Collaborates with members of the healthcare team concerning patient’s assessment, goals, care plan and progress.
• Performs ongoing assessments of patients for continuing care needs such as, Skilled Nursing Facilities (SNF’s), acute Long Term Care Facilities, Durable Medical Equipment (DME), and Home Health.

Discharge Planning/Quality of Care:

• Participates in Multidisciplinary Rounds (MDR) to assist with the development of care plans that will meet the patient’s current and continuing healthcare needs.
• Serves as an advocate for the patient and protects patients’ rights as they pertain to the ethical and legal issues of confidentiality during the case management process.
• Based on patient assessment, develops a discharge plan, per KHI’s Discharge Planning policy, to coordinate the provision of goods and services with referrals to specific providers, and ensures initial implementation of the discharge plan in collaboration with the Discharge Care Coordinator.
• Based on patient’s assessment and collaboration with the healthcare team, and the patient/family, the Case Manager develops and documents the discharge plan by identifying the needs of the patient and the availability of resources to ensure a safe transition from the hospital. The Case Manager assists patients and their families with needs, such as complex discharge planning needs, suspected emotional, cognitive, or mental problems, financial issues, and home/environmental issues. When identified, refers all suspected child and elder abuse/neglect concern to the appropriate agency.
• Participates in MDR to ensure effective communication and collaboration for patients identified as having complex needs.

Utilization:

• When necessary, determines which cases will require medical staff review and/or UR management intervention based upon KHI’s Utilization Management Plan. Factors such as cost/benefit, appropriateness, availability of resources, quality, prior authorization requirements, and patient choice are taken into consideration during the case management process.
• Communicates with the attending physician, expected length of stay, Medicare guidelines and individual variances.
• Proficiently utilizes MCG and applies clinical guidelines and criteria appropriately to make utilization determinations. Inputs data into MCG when needed. Communicates frequently with the UR Nurse and provides requested data timely.

Compliance:

• Participates in committees, performance improvement activities, mandatory in-services, and continuing education.
• Maintains compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines.

Additional Duties:

Performs additional duties, as requested, such as focused studies, appeal letters, outlier reporting, etc.

Specialty Specific Responsibilities

ED Case Manager:

In collaboration with Emergency Department (ED) providers, screens patients to identify those that require admission with identification of appropriate level of status assignment, those that do not require admission, and those with multiple presentations to the ED who may require intervention to avoid future unnecessary ED visits. In addition, the ED Case Manager ensures the unit base Case Managers have the appropriate information when the patient is admitted.

• Completes initial UR review on 100% of patients admitted during scheduled shift and completes all data entry into required documentation tools prior to end of shift.
• Assists with appropriate compliance of regulatory requirements, both State and Federal, including delivery of Hospital Initiated Notices of Non-coverage (HINN).
• Reviews non-emergent transfers into the hospital for medical necessity of admission.
• Provides physicians with alternatives to admission when patients do not meet medical necessity guidelines for admission to the facility.

Pre-Access Case Manager:

The Pre-Access Case Manager screens direct or scheduled admissions for appropriateness of admission and facilitates placement to the appropriate level of care for both scheduled admissions and transfers of care. The Pre-Access Case Manager intervenes as necessary when criteria are not met. In addition, the Pre-Access Case Manager initiates UR documentation for those patients that have been screened but will be followed by the unit-based Case Managers. The Pre-Access Case Manager may provide ongoing support and expertise to the healthcare team. This collaborative process requires communication and coordination with the referring physician, staffing office, and payors. The Pre-Access Case Manager is responsible for assisting in maintaining a financially stable department, promoting their own professional development with an emphasis on evidence-based practice and education.

• Reviews surgery and OP procedure schedules to verify appropriate planned status assignment.
• Intervenes with Physician and Physician Office staff to address any procedure planned for a status not meeting level of care guidelines (e.g., Medicare IP Only procedures).
• Maintains current knowledge related to payor guidelines in reference to certification/authorization, ensuring payment for admission.
• Pre-screens direct admissions and facilitates physician to physician discussion.
• Identifies scheduled admissions and transfers not meeting level of care criteria and communicates concerns to the Physician Advisor and/or our external review organization as indicated.
• Communicates process or physician related concerns to the Director and/or Physician Advisor immediately when identified.
• Verifies that the patient’s insurance has approved admission before accepting non-emergent patients from another facility.
• Determines and communicates the appropriate patient status to the admitting department as applicable.
• Communicates pending transfer cases to the appropriate case manager.

Education:  Graduate from an accredited school of nursing or bachelor’s degree in related health/behavioral/social science field.

Experience:  At least one (1) year acute care setting experience or three years sub-acute experience.

License:  RN’s must be licensed and currently registered as an RN in the state of Arizona.

Certification:  BLS through the American Heart Association or American Red Cross.

Knowledge, Skills, and Abilities:

• Effective problem-solving skills, including the ability to analyze complex situations, draw conclusions and implement actions appropriately and efficiently.
• Knowledge of community resources to meet post-discharge clinical and social needs.
• Possesses excellent interpersonal communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues.
• Strong analytical and PC skills.
• Ability to work cooperatively and develop collaborative relationships with physicians, families, patients, interdisciplinary team, and other community agencies.
• Ability to work with people of all social, economic, and cultural backgrounds; be flexible, open-minded, and adaptable to change.
• Demonstrates the ability to connect patients and families with necessary services, both inside and outside of Kingman area.
• Maintains a current working knowledge of services available in the local community, particularly services available to patients with limited payment resources.

Specialty Specific

ED Case Manager:

Minimum of three years varied acute care hospital experience.

Pre-Access Case Manager:

Minimum of two years of clinical experience in medical surgical or critical care nursing.

Education:  Graduate from an accredited school of nursing. MSN or Master’s in related health/behavioral/social field.

Experience:  Experience in utilization management, case management, discharge planning, and/or quality improvement.

Certification: ACMA or CCM.

Knowledge, Skills, and Abilities:

• Knowledge of clinical, social, insurance/financial, and physical factors that must be considered when evaluating how a patient’s expected post discharge care needs can be met.
• Knowledge of clinical and social factors that may affect the patient’s functional status at discharge.

Specialty Specific

ED Care Manager:

• Three to five (3-5) years of recent acute hospital care experience.
• One to two (1-2) years of experience in Utilization Management or Case Management.

Pre-Access Care Manager:

• Certified care manager (CCM) or accredited care manager (ACM).
• Three to five (3-5) years of clinical experience in medical surgical or critical care nursing.
• Two (2) years of experience in Utilization Management or Case Management.

• Exposure Category I: Expected duties have routine potential for exposure to blood, body fluids or tissues.
• Other potential Hazard(s): Volatile/violent patients or family members.

• Able to handle multiple priorities simultaneously.
• Demonstrates strong oral and written communication skills.
• Able to manage technical business equipment i.e., phone, fax, computer etc.
• Ability to sit for 3-5 hours per day.
• Ability to stand for 3-5 hours per day.
• Ability to walk for 3-5 hours per day.
• Availability to work some evenings and weekends.