Registered Nurse/ Licensed Vocational Nurse Case Manager- FT - Nights - Resource Management
Company: DHR Health
Posted on: January 7, 2021
POSITION SUMMARY:Under the general supervision of the Case
Management Coordinator, the RN/LVN Case Manager acts as a patient
advocate to hospital clients. An autonomous role that coordinates,
negotiates, procures services and resources for, and manages the
care of complex patients to facilitate achievement of quality and
cost efficient patient outcomes. The RN/LVN Case Manager identifies
opportunities to reduce cost while ensuring the highest quality of
care is maintained. Review criteria are applied to determine
medical necessity for admission and continued stay. The RN/LVN Case
Manager provides clinically based case management, discharge
planning, and care coordination to facilitate the delivery of
cost-effective quality healthcare and assists in the identification
of appropriate utilization of resources across the continuum of
care.The RN/LVN Case Manager works collaboratively with
interdisciplinary staff internal and external to the organization,
and participates in quality improvement and evaluation processes
related to the management of patient care. The case manager is
on-site and available seven days a week, as well as holidays and,
therefore, is required to work a weekend rotation and an occasional
holiday and will required to be on call.POSITION
- Graduate from an accredited school for nursing required.
- A valid license as a Registered Nurse or Licensed Vocational
Nurse with the State of Texas is required.
- Certification in Case Management (CCM) is highly desired.
- Candidate must demonstrate proficiency in both the English and
Spanish language.JOB KNOWLEDGE/EXPERIENCE:
- Knowledge in the areas of case management and utilization
management, experience with Managed Care and utilization management
as it relates to third-party payers preferred.
- Three to five years clinical experience is required, with
experience in a Hospital or acute care setting being strongly
- Experience in use of InterQual and or Milliman criteria and
review processes highly desirable.
- Knowledge and understanding of Medicare and Medicaid guidelines
and regulations pertaining to utilization review and discharge
- POSITION RESPONSIBILITIES:
- Assists in the development and implementation of the case
- Collaborates with already existing programs and departments to
ensure appropriate resource utilization by all patients being
followed in a caseload.
- Works with nurse managers, other clinical departments, and
division directors in program development.
- Establishes and/or attempts appropriate caregiver forums to
provide program teaching/information and seeks program
- Provides orientation and ongoing education specific to case
- Participates in extending case management approach.
- Acts as a consultant to all disciplines specific to case
- Performs ongoing evaluation of case management program.
- Participates in daily rounds, providing education to other team
members re: Case Management
- Provides follow-up to system issues and reports individual
practitioner variances appropriately to PA or Department
- Participates in respective nursing unit meetings providing Case
Management education and new regulatory requirements as needed per
the Case Management Supervisor.
- Directs, coordinates, and provides case management to patients
- Assesses the patients within the caseload to identify needs,
issues, resources, and care goals.
- Through proper reporting mechanisms, completes case management
assessment, reviews admitting diagnoses/problem(s), determines plan
to address client's needs, and optional/preferred level of
- Develops a discharge plan early on in admission.
- Implements and coordinates interventions that will lead to
goals in plan.
- Monitors the effectiveness of the plan.
- Participates in case finding and preadmission evaluation
screening to ensure reimbursement.
- Identifies potential transition planning problems in a timely
manner to set up services required.
- Works with attending physician and care team members to move
patient through the hospital system and set up appropriate services
- Identifies need for new resources if gaps exist in service
continuum and initiates creative care delivery options
- Reviews the medical records of all observation and inpatient
admissions to determine the medical necessity for admission and
continued stay, using pre-established criteria (InterQual or
Milliman) with appropriate frequency.
- Continues review of all patients using criteria and determines
need for continued hospitalization based upon third party
- Assesses clinical, including psychosocial, system
- Establishes planning to determine goals and objectives and care
setting to optimally meet patient needs. Develops a discharge plan
in a timely manner.
- Conducts necessary conferences and team meetings regarding
specific patient needs.
- Implements interventions that lead to the patient accomplishing
goals established in plan.
- Coordinates the necessary resources to accomplish goals
developed in plan.
- Proactively affects system to facilitate efficient flow of
- Gathers information from sources to enable case manager to
monitor the plan's effectiveness.
- Evaluates the effectiveness of the plan (including variance) in
reaching patient's outcomes and goals.
- Makes appropriate changes to plan as necessary.
- Documents patient/patient representative understanding of case
- Documents avoidable day and /or delay in service variances as
- Recognizes and immediately intervenes in cases of suspected
abuse or neglect.
- Recognizes National Patient Safety Goals and Core Measures as
applicable to the patient populations served.
- Plays an essential role in assisting physicians, nurses, and
staff with an accurate determination of a patient's observation
status. The case manager is an important resource in preventing
delayed discharges of observation patients.
- Identifies and monitors observation admissions daily, to
determine the correct patient status.
- Consults with physicians, nursing, admitting, and outside
insurance case managers to determine the appropriate status of
- Assumes the role of review coordinator for observation
services; reviews medical record for appropriateness of status and
level of care and facilitates the level of care, utilizing
InterQual or Milliman for observation.
- Works with physicians, nurses, staff, patients, and families to
arrange prompt and safe discharge.
- Case managers must take telephone orders from physicians
changing patient status from observation to inpatient admission.
This should be done when monitoring observation status. A call or
page should be made to a physician if the case manager believes
that this should be an inpatient admission and should not wait
until the 24 hours are ending before conversion. Case managers must
actively monitor patients on observation status and seek to clarify
their status as close to the 24-hour benchmark as possible.
- Develops a discharge plan with nursing when appropriate.
- Completes daily Observation log in a timely manner.
- Accurately applies InterQual or Milliman criteria 95% of the
time in determining status. Refers appropriately to the PA when
medical decision making determination is necessary.
- Consistently follows Condition Code 44 policy when IP status
requires changing to Observation for Medicare patients 95% of the
- Consistently follows the Observation policy for all other
payers. (correct determination of start time)
- Reviews the medical records of all inpatient admissions to
determine the medical necessity for admission and continued stay,
using pre-established criteria.
- Identifies cases that fail daily to meet criteria and refers
these cases to appropriate physician advisor.
- Assists and educates attending physicians on an on-going
- Contacts the attending physicians daily on cases that lack
adequate documentation warranting acute hospitalization.
- Contacts the attending physician to notify him or her of the
decision to issue notice of non-coverage. Explains UR process and
insurance coverage requirements. Obtains physician's written
concurrence when necessary.
- Informs the patient and/or next of kin when insurance coverage
must be terminated for the current admission. Issues HINN
- Reinstates insurance coverage when the patient's condition
becomes acute and meets criteria again. Issues reinstatement
- Continues review of all patients using criteria and determines
need for continued hospitalization based upon third party
- The initial review applying InterQual criteria is completed
within 24 hours of admission.
- Continued Stay Review is completed no greater than every 48
hours (72 hours for Critical Care) or more frequently as dictated
by discharge screening criteria.
- Document timeframe for next review 95% of the time.
- Proceeds to issue Hospital Issued Notice of Non-coverage and
Hospital Requested Review for Medicare patients according to
- Refers cases not meeting criteria appropriately, following
contract requirements for all other payers.
- Completes case management assessment of patients and support
systems in order to facilitate the most appropriate and timely
- Introduces self to the patient/family, explains the case
manager role, and provides them with a business card.
- Assesses documentation in the medical record appropriate to
level of care.
- Documented level of care recorded when needed prior to nursing
- Begins to prepare patient/family regarding optional pathway for
care including several complications/options that may occur.
- Provides transitional planning information to patient or
patient's representative 24 hours before discharge when
- Documents referrals to nursing homes, rehab, hospitals, and
- Documents meetings with family, patient, or doctor.
- Assembles necessary referrals, discharge summary, and pertinent
information for placement prior to the day of discharge.
- Sends forms to institutions or home health agencies within 48
hours of discharge when appropriate.
- Documents home-care lists and alternate level-of-care
facilities lists provided to families when appropriate.
- Offers choice to Medicare patients and completes documentation
as outlined in the policy.
- Initiates the Important Message to Medicare policy for when
discharge has been determined to be within 48 hours or less.
- Utilizes support staff efficiently. (transportation, FAXing to
agencies, chart copying)
- Communicates the discharge plan to patients/ patient
representatives and pertinent healthcare team members.
- Collaborates with Quality Management Department: Performs
quality assessment reviews and studies both concurrently and
retrospectively as required by the hospital's PI plan, JCAHO
standards, and third-party payer regulations.
- Applies generic quality screens/indicators concurrently to
patient medical records and accurately abstracts relevant patient
care data to determine if quality screens are flagged. Performs
first line reviews on potential quality issues as requested by
- Refers all other potential quality of care issues identified,
not reviewed, as part of the quality assessment screening to the
physician advisor to facilitate timely follow up.
- Collects potentially avoidable day data for system Performance
- Refers potentially avoidable day cases to the PA when the
medical staff triggers are met.
- Refers quality issues to the Case Management Supervisor, CMO
and/or PA appropriately.
- Provides clinical data/information to contracted third-party
payers while patient is hospitalized to ensure continued
reimbursement and to avoid reimbursement delays within 24 hours of
- Accurate InterQual and Milliman documentation that meet the
requirements of third party payers for admission certification and
continued stay approval is documented 95% of the time.
- Interacts, communicates, and intervenes with multidisciplinary
healthcare team in a purposeful, goal-directed fashion. Works
proactively to maximize the effectiveness of resource
- Anticipates, initiates, and facilitates problem resolution
around issues of resource use and continued hospitalization and
- Establishes a means of communicating and collaborating with
physicians, other team members, the patient's payers, and
- Utilizes appropriate resources in cases that present ethical
- Explores strategies to reduce length of stay and resource
consumption within the care-managed patient populations, implements
them, and documents the results.
- Communicates to appropriate members of healthcare team the
patients at risk of losing insurance coverage or HINN notification
of Medicare and Medicaid patients.
- Maintains a proactive role to ensure appropriate documentation
concurrently to minimize inefficient resource utilization and
prevent loss of reimbursement.
- Reviews physician documentation and, when needed, follows
procedures to seek clarification of documentation relative to
diagnosis and comment, on the patient's clinical state
- Participates in daily rounds on nursing units
- Refers to PA those cases in which appropriate resource
utilization is to be evaluated, such as IP MRI, IP endoscopy, or
whenever the test ordered does not relate to the reason for
admission or diagnosis/symptom
- Other duties as assigned.LINES OF RESPONSIBILITIES:
- Director of Resource Management
Keywords: DHR Health, Edinburg , Registered Nurse/ Licensed Vocational Nurse Case Manager- FT - Nights - Resource Management, Healthcare , Edinburg, Texas
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