RN Case Manager - Relocation Offered! - Full-time

The Case Manager is responsible for facilitating the patient's hospitalization from admission through discharge. The Case Manager coordinates with physicians, nurses and social workers and other disciplines within the care team, including outside agencies, to expedite the appropriateness, effectiveness and timeliness of care. Applies clinical expertise and medical appropriateness criteria to resource utilization and discharge planning, and manages the resources necessary for cost effective, quality patient care. This position includes meeting the needs and providing services to all age groups-infancy through geriatrics, as well as providing services for the culturally diverse population Washington Hospital Center serves.
Education

• Bachelor's degree in Nursing required
• Associate degree in Nursing with five years of bedside nursing experience can be used in lieu of the Bachelor degree requirement.

Experience

• 5-7 years of broad clinical experience in the acute care setting required
• Experience in case management, quality management and utilization experience preferred

Licenses and Certifications

• RN - Registered Nurse - State Licensure and/or Compact State Licensure in the District of Columbia required

Assesses assigned patient cases to identify case management needs and collaborates with the physician and the patient/family to identify desired outcomes and develop a plan of care.

Leads the coordination of patient care with other disciplines within the care team, monitoring the appropriateness and timeliness of care.

Ensures the interdisciplinary care plan is consistent with the patient's clinical course, continuing care needs, covered services and estimated length of stay by monitoring diagnostic testing, treatments and procedures throughout the continuum of care.

Screens and completes admission assessment within 24 hours of admission on all newly admitted patients. Identifies at risk patients/families and refers complex discharge needs to the clinical social worker.

Applies InterQual or MCG criteria and advanced clinical knowledge to determine medical necessity, appropriate level of care, appropriate resource utilization, optimal insurance coverage and timely discharge.

Performs the UR functions for their assigned cases. Validates admission and continued stay reviews with physician and third party payers. Takes appropriate action when level of care determinations are not in alignment with clinical information. The Case Manager will escalate to the physician advisor when appropriate for review.

Develops and implements discharge plans for assigned patients, in collaboration with the interdisciplinary team, patient/family, payor, and external resources.

Collaborates with third party payors to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent the denial where possible.

Actively contributes, participates and follows through on interventions identified in Department Long Stay Rounds and Unit Discharge Planning Rounds.

Maintains current knowledge of clinical treatment modalities related to assigned patient populations, quality and clinical improvement strategies, and reimbursement issues.

Maintains accurate, concise, and timely documentation in Allscripts and other WHC record-keeping systems according to standard practice.

Identifies consistent actual and/or potential issues related to quality, length of stay and reimbursement, and communicates them to department leadership using established procedures.

Assists with departmental projects and other functions as assigned to support department operations and/or assist with patient specific issues that may arise.