Department:Case Management, 87141
Under the general supervision of the Director, nurses in the RN Case Manager role provide clinically based case management to support the delivery of effective and efficient patient care. Places cases from physiological and economic perspectives. Has overall accountability for the utilization management and transition management for patients within the assigned caseload. Partners with Social Work Case Managers, and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement. Utilizes criteria to confirm medical necessity for admission and continued stay. With the patient, family, and health care team, creates a discharge plan appropriate to the patient's health care needs and resources.
QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Registered Nurse with active Washington license or eligible for licensure.
BSN preferred or actively working on BSN
SPECIALIZED TRAINING REQUIRED:
Proficiency with Interqual criteria preferred
LICENSE / CERTIFICATION / REGISTRATIONS REQUIRED:
RN license in Washington State and a WA State Driver's License
Case Management Certification preferred
CONTINUING EDUCATION & COMPETENCY REQUIREMENTS:
Continuing education and/or licensing requirements:
As required for RN license
Population Specific continuing competency requirements:
Minimum of 5 years of broad clinical experience, predominantly in medical/surgical nursing.
Case Management, discharge planning, and utilization review experience preferred.
KNOWLEDGE / SKILLS / ABILITIES:
Knowledge, understanding and application of various Hospitalization Healthcare Guides (e.g. InterQual; Milliman, Medicare/Medicaid regulations)
Knowledge of medical terminology, anatomy and physiology; medical procedures; normal and abnormal clinical findings and their implications for care needs
Demonstrates ability to engage in complex clinical decision-making
Demonstrates a working knowledge of common diseases treated in the Emergency Department and age-specific characteristics of these diseases.
Demonstrates ability to differentiate between normal and abnormal physical and psycho-social findings.
Demonstrates ability to interpret diagnostic screening results, including results for laboratory and radiological procedures routinely performed in the ED.
Demonstrates working knowledge of insurance reimbursement arrangements for acute and emergency services.
Demonstrates a strong commitment to interdisciplinary collaboration and communication.
Demonstrates strong skills in the preparation of clinically pertinent medical record documentation.
Demonstrated skills in collaboration, teamwork and problem-solving to achieve goals
Demonstrates skills in verbal communication, teaching and listening
Demonstrates skills in providing excellent service to customers
Skilled in interacting with Physicians on a collegial basis
Demonstrated Window based computer skills (word processing, data entry at a minimum)
Ability to accept and transcribe Physician verbal/telephone orders
Able to participate in external case management activities
Able to function independently while achieving shared goals for patients/Harrison Medical Center/payors
Self-directed ability to prioritize and, when necessary, re-prioritize workload
Demonstrated ability to complete work within required timeframes
Demonstrated ability to maintain confidentiality
ACCOUNTABILITIES AND ESSENTIAL JOB FUNCTIONS:
Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents information in the current system.
Validates admission and continuing stay criteria with third party payers (including onsite and telephonic Case Managers) as well as Primary Care and Attending Physicians. Recommends alternative care sites where appropriate.
Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent the denial where possible.
Supports the effective prevention and management of denials, including drafting appeal letters and/or providing information as part of the appeal process.
Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a plan for discharge.
Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan. Supports the process of patient choice in establishing a discharge plan.
Uses clinical knowledge and knowledge of anticipate response to treatment to assess patient progression towards anticipated outcomes. Communicates and coordinates with the patient/family and health care team to Intervene when progression is stalled or diverted. Addresses actual/potential barriers to discharge
Completes the interventions necessary for discharges to home with self-care, home with services and short term skilled nursing facility placement. Assembles necessary referrals, discharge summaries and pertinent information for placement prior to the day of discharge.
Actively contributes to, participates in, and follows through on interventions identified in care coordination and complex patient rounds.
Identifies high risk patients and creates a collaborative plan to address their unique needs.
About Harrison Medical Center:
For more information about what it's like to