Case Manager

POSITION SUMMARY

The Nurse Case Manager primarily performs screening for all residents in a bed for medical necessity, reviews for appropriateness of setting, utilization, care planning, quality and facilitates their admission to the facility.

POSITION ESSENTIAL DUTIES AND STANDARDS

• Performs admission necessity screening using criteria as established by the various federal, several state and private sector programs.

• Performs concurrent reviews for appropriateness of utilization, care planning, quality indicators to optimize clinical and financial outcomes. Evaluates and revises plan of care as needed.

• Communicates with physicians, resident/POA, members of the health care team, Coordinated Business Office (CBO) staff, Denial Management Specialist and third-party payers.

• Notifies appropriate staff member(s) of any admission, service, length of stay, lack of medical necessity criteria, PASSAR status, ability to pass a PAE for long term placement, as well as denials/appeals and issuing of ABN letters to residents/POA.

• Implements and follows Nursing Home (SNF and ICF) case management guidelines and procedures in practice.

• Identifies present and anticipates future learning needs of resident, family, staff and physicians related to compliance, medical necessity and payor guidelines.

• Provides information on compliance and payor regulations and restrictions. Able to preauthorize/pre-cert for payor sources.

• Initiates/participates in resident/family/physician/staff conferences related to admission, plan of care and discharge plan.

• Assists with co-workers education as needed.

• Demonstrates competence in basic case management skills.

• Demonstrates basic knowledge of specific criteria as it relates to appropriate levels of care for facility approved age groups.

• Practices proficiency in technical (computers, software programs, cell phones) and special skills relevant to case management.

• Maintains established safety, environmental, and infection control standards and takes appropriate corrective action for identified infractions.

• Maintains current knowledge base for regulations, state, federal, private and clinical necessity to fulfill job requirements.

• Maintains current knowledge of department standards and is a resource for other departments and members of the healthcare team.

• Able to accurately evaluate complex residents with multi-system problems.

• Able to assess and develop appropriate case management interventions for residents of assigned unit.

• Reviews disease process, treatment plan, potential complications, potential financial risk and areas for concern and communicates with appropriate physician, staff member, and director/designee in order to develop an individualized improved plan.

• Is accessible and open to staff nurse/physicians questions or concerns.

• Works collaboratively with nursing staff, Social Service Coordinator, Rehab Director and Department Directors in: Participating in the review/revision of policies, procedures, teaching materials, and performance improvement activities. Communicates/educates as needed with payors and referring facilities/persons such as families, Hospitals, Skilled/Nursing homes, Home Health/Hospice, Rehabs etc.

KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of case management principles, procedures, and practices.

• Must be able to assess, interpret, and appropriately react to key data about a resident’s case in a timely manner.

• Ability to recognize complex resident cases, react appropriately and alert appropriate team members/payers to issues.

• Must be able to identify and provide for age-specific and disease-specific resident needs in relation to medical necessity, compliance, quality and payor guidelines.

• Skill in operating job related equipment

• Excellent communication/interpersonal skills, strong decision-making abilities, organizational/problem-solving skills and team-building skills with ability to function independently and interdependently as a member of healthcare team.

• Must be flexible in work assignments and coverage of admission tasks.

EDUCATION:

• Must be certified by the State of Tennessee approved program or will complete certification program within four months of initial employment. Graduate of an accredited school of practical nursing. Must be currently licensed in Tennessee and must present license for verification at time of employment and every two years according to the license renewal schedule as determined by the Tennessee Board of Nursing.

EXPERIENCE:

At least one year experience preferred in N

PHYSICAL DEMANDS/WORKING CONDITIONS:

• To be able to lift up to 20 lbs.

• To be able to reach, bend, kneel and squat.

• To be able to walk and stand on a repetitive and constant basis.

• To be able to use step stools.

• To be able to hear call system, pager signals and spoken English language.

• To be able to wear protective gloves supplied by the facility.

• Nursing Home Case Management admission process.