Job Description

Job Description

Oversees a staff of case managers responsible for patient care coordination. Develops and implements case management programs, including utilization review, intake or discharge planning, and managed care contracting or negotiation. Evaluates patient care data to ensure that care is provided in accordance with clinical guidelines and organizational standards. Seeks treatments that balance clinical and financial concerns with the family's needs and the patient's quality of life. Relies on extensive experience and judgment to plan and accomplish goals. Performs a variety of tasks. Leads and directs the work of others. A wide degree of creativity and latitude is required. Typically reports to top management. Requires certification as a registered nurse with at least 5-7 years of clinical exper

Case manages high volume, high lengths of stay high risk and high cost patients. Utilizes census report to prioritize workload daily.
Prioritizes workload based on LOS, DRG, charges, and payer reimbursement.
Monitors patients progress to ensure care is streamlined, appropriate, and timely.
Evaluates patients through chart review, physician and nurse interview, and patient assessment within one working day of admission: Performs clinical/psychosocial assessment.
Establishes expected daily and stay clinical outcomes.
Initiates plan of care/triggers and reviews with staff within one working day of admission.
Responsible for managing the daily operations of the department. Organizes department hierarch/structure in a manner that results in efficiency, effectiveness, and responsiveness.
Establishes short and long term goals in order to be consistent with NHS and CHS goals.
Appropriately delegates while maintaining responsibility and accountability for delegated tasks.
Responsible for staff performance, recruitment, retention and staff development.
Improves subordinate performance through on-going counseling, coaching, delegation, and feedback practices and monitors threat standards are consistently being met.
Interacts with physicians, nurses, and other health care team members to facilitate plan of care: serves as resource for physicians and staff regarding patient progress.
Participates in physician rounds, discharge planning meetings and patient care conferences.
Oversees the function of case management including performance improvement, case management to ensure that patient care is appropriate, timely, cost effective, and achieves desired outcomes.
Assists in coordination of ancillary services: ensures actions taken on all orders and intervenes with other departments to obtain services when necessary.
Ensures test results are routed daily.
Performs Resource Utilization on all patients to reduce inefficiency/cost: Evaluates over-utilization/under-utilization and follows-up with physician.
Monitors observation stays: ensures timely admission or discharge within 24 hours. Utilizes HBOC report to monitor outpatient stays daily.
Improves and monitors quality of care: identifies and documents variance from expected outcome for each case. Assembles variances and reports to supervisor in timely manner.
Utilizes HBOC UM program and Inform Outcome Analyst: tracks Avoidable Days daily and reports to supervisor. Presents variance data/physician profiles to medical staff committees quarterly.
Works effectively with pre-certification nurse to ensure pre-authorization of insurance: Provides clinical information to insurance/pre-cert within 24 hours of notification.
Performs continued stay reviews within 48 hours of initial review.
Documents patient days/authorization numbers in HBOC account notes.