Registered nurse case manager

    Cleveland Clinic
    Vero beach, FL
    Full-time, Part-time
    Similar jobs pay $24.85 - $29.51

    Job Description


    BASIC FUNCTION: The Case Manager RN, in partnership with physicians, nursing and healthcare team members, utilizes professional skills to assess patient and family needs for medical and psychosocial needs and establishes plans for effective management throughout the continuum of care. The Case Manager RN role also includes proactive, individualized planning for patients' progress across the continuum that optimizes quality of care, patient satisfaction, and utilization and reimbursement to meet organizational strategic objectives.

    : None

    NATURE AND SCOPE: This position will communicate and interact with patients, families, physicians, both CCIRH and external, as well as outside agencies, payers, CCIRH nursing and other staff, as well as management.

    Supports the mission, vision and values of the hospital.

    Responsible for working in a safe and protective manner at all times, keeping in mind that safety and environmental hazards are the responsibility of all employees for themselves, other staff members and patients.

    Assessment and planning of individual needs in order to develop a comprehensive case management plan that will address those needs. Screens patient population within one working day for high-risk needs, including physical, psychosocial, and financial indicators and makes referrals to appropriate discipline.

    Identifies cases requiring intervention and proceeds as necessary in a timely and effective manner.

    Assumes leadership role in managing cases and establishes optimal plans that are executed in a timely manner.

    Discusses assessment findings and patient status with physician and /or treatment team to maximize outcomes.

    Collaborate with staff and treatment team to modify plan of care, as needed, as key clinical and financial information is identified.

    Confers, as appropriate, with physicians and/or physician advisor to review and clarify medical appropriateness of treatment plan for identified patients.

    Monitors the patient's progress towards meeting physical, emotional, educational, financial and spiritual health goals by addressing any variances in the pathways, protocols, etc., to ensure optimal outcomes.

    Coordinates services required for patients in collaboration with the clinical treatment team and with payors to ensure services are provided across the continuum.

    Accepts telephone, fax and electronic requests for clinical information and responds in a timely manner providing necessary demographic and clinical information to facilitate certification of inpatient stay and procedures performed.

    Serves as a liaison to community services.

    Demonstrates knowledge of resources available in the system, regardless of geographic location and utilizes effectively in discharge preparations.

    Facilitates transition planning across the continuum by involving patient, family, physician, staff nurse and any other disciplines.

    Advocates on the patient's behalf for scarce resources or for additional resources if gaps exists.

    Performs admission and continued stay review for patients based on established criteria and sound clinical knowledge for the purpose of monitoring appropriateness of inpatient stay and services. Monitor observation vs. in-patient status.

    Responsible for retrospective submission of patient information as indicated.

    Responsible for alerting patient if they are in observation status and what that means to them financially.

    Confers, as appropriate, with physicians and/or physician advisor to review and clarify medical appropriateness of treatment plan for identified patients.

    Refers all questions of medical necessity on admission and continued stay in a timely manner to the physician advisor.

    Intervenes as needed to prevent denial of coverage issues. Identifies potential denials in a timely manner and communicates appropriately to the leadership team.

    Provides denial to patients per protocol, as appropriate, when admission criteria or level of care criteria are not met. Explains appeal process to patient and/ or family members.

    Identifies and analyzes variances from expected outcomes and actively works towards resolution.

    Monitors the treatment plan for the quality, quantity, timeliness and effectiveness for services provided, to ensure that they are appropriate, cost-effective and maximize outcomes.

    Assigns avoidable days per policy.

    Identifies and reviews documentation deficiencies with appropriate department.

    Maintains and interprets utilization review statistics as required by federal, state, and third-party payer regulations and reimbursement guidelines.

    Fosters cordial, positive and professional relationships with patients, family members, physicians, members of the healthcare team, insurance companies, community agencies and peers.

    Negotiates effectively with patients, family members, physicians, insurance companies, other providers, community agencies, staff and peers to provide efficient and successful patient transitions through the continuum.

    Documents case management plan including assessment, plan of care, interventions, and appropriate resources by the end of each working shift in order to ensure a complete, accurate medical record.

    Supports CMS Important Message (IM) to include appropriate delivery of the Important Message from Medicare Discharge/Appeal Notice to patients and /or healthcare surrogates, providing availability to answer questions as needed.

    Maintains adequate and timely progress notes in each patient's medical record.

    Utilizes PC communication tools in a timely and effective manner: monitors e-mails, voicemails throughout the day and responds within the same day.

    Identifies administrative issues that may affect reimbursement or increased length of stay (insufficient medical record documentation, lack of timely test or treatment, etc.). Communicates findings to appropriate department or individual to ensure maximum coverage and reimbursement.

    Ensures that quality of care concerns are reported to the appropriate staff person and/or risk management department.

    Identifies patients requiring nursing home, transitional care or rehabilitation placement, and making the appropriate referral.

    Patients requiring supportive counseling or psychosocial issues or assessments due to homelessness, psychiatric issues or substance abuse will be referred to the social work case manager.

    Acts as a proactive member of the multi-disciplinary discharge planning team providing a safe discharge from acute care services.

    Collaborates with healthcare team in providing client/family education related to patient's diagnosis.

    Assists in education medical and multidisciplinary staff on regulatory guidelines, utilization review issues, transition planning, development and use of protocols.

    Reviews payer and/or contract updates to maintain working knowledge of new developments in the screening criteria and coverage guidelines used in the utilization process.

    Maintains current knowledge of and effectively applies Interqual guidelines, Medicare and other regulatory criteria for medical appropriateness and utilization optimization.

    Maintains current knowledge of The Joint Commission guidelines. CCIRH Utilization Review Plan, DRG and reimbursement with expected length of stay.

    Possess a working knowledge of financial terms, i.e., PPO, HMO, and patient requirements/expectations.

    Maintains professional knowledge of discharge planning concepts and community resources and utilization management legislation.

    Adheres to scheduling to include weekend rotation.

    Performs other duties as assigned.

    Ability to interact well with others and be a team player.

    Excellent communication skills, both written and verbal.

    Must have excellent organizational and problem-solving skills.

    Demonstrates tact, diplomacy, negotiation skills and customer relations.

    Ability to work independently.

    Ability to prioritize assignments and effective time-management skills.

    Must be detail oriented, flexible and committed to patient advocacy.

    : Current licensure as Registered Nurse in the State of Florida; BSN preferred.

    Minimum of three (3) years of recent acute clinical experience preferred.

    Previous Interqual-based criteria and/or medical necessity review experience preferred.

    PC proficiency with Microsoft office products; experience with Interqual and Midas preferred.

    Basic knowledge of clinical and psychosocial aspects of patient care.

    Physical Demands: Light work - lifting up to 20 pounds on an infrequent basis (less than one lift every three minutes) and/or carrying up to ten pounds, or requiring walking or standing to a significant degree (about six hours a day).

    Ergonomic Risk Factors: Repetition: Repeating the same motion over and over again places stress on the muscles and tendons. The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved.

    Awkward Posture: Posture is the position your body is in and its effect on the muscle groups that are involved in the physical activity. Awkward postures include repeated or prolonged reaching, bending, kneeling, squatting, working overhead with your hands or arms, or holding fixed positions.

    Working Conditions: Blood borne Pathogen Exposure Risk Category B: MAY have exposure to blood or body fluids.

    CCIRH is a drug and nicotine free workplace

    The policy of Cleveland Clinic and its system hospitals (Cleveland Clinic) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic's Smoking Policy will be permitted to reapply for open positions after 90 days. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic facility.

    Cleveland Clinic is pleased to be an equal employment employer: Women/Minorities/Veterans/Individuals with Disabilities
    Posting ID: 556644754Posted: 2020-05-21