Catholic Health Initiatives RN Case Manager, Care Management, Jewish Hospital, Nights, Full Time in LOUISVILLE, Kentucky

RN Case Manager, Care Management, Jewish Hospital, Nights, Full Time

Description

Under

the direction of the Director, Care Coordination, the Case Manager performs

activities which support the Case Management/Utilization Management function.

The Case Manager promotes optimal health care outcomes in accordance with the policies,

procedures, applicable laws and contracts, philosophy, mission and values of

University Hospital; assumes responsibility and accountability for the

appropriate utilization of facilities and services; serves as a resource to

physicians; conducts admission and concurrent reviews including observation and

inpatients; identifies patients who do not meet criteria and takes action to

ensure patients are cared for in the most appropriate level of care;

coordinates care in conjunction with other members of the interdisciplinary

healthcare team to provide and facilitate optimal health care/discharge

planning; utilizes the nursing process (assess, plan, implement and evaluate)

and management process (plan, organize, direct and control) to provide a

framework for decision-making; maintains confidentiality of information;

actively supports organizational goals and objectives by providing needed

information to divisions and departments.  

Job Duties:

Promotes optimal management of clinical resources by conducting timely

admission and concurrent utilization review for all patients of designated

medical services. Certifies medical necessity for admission, continued stay and

discharge reviews for patients certified by utilizing the current InterQual

criteria. Documents clinical information in Case Management Software system.

Utilizes and contributes to the development of the multidisciplinary clinical

assessment of patients on an on-going basis during the patient’s admission to

ensure the quality and appropriateness of patient care.

During the concurrent review process, evaluates the medical record to identify

any process delay impacting the timeliness of patient care in a collaborative

effort to ensure that the appropriate resources are utilized (i.e. physical therapy,

cardiac rehabilitation, or nutritional service).

Identifies patients and/or families with post discharge continuity of care

needs by screening medical records, and through collaboration with the health

care team and the patient and/or family, identifies and coordinates services.

Considers factors such as the patient’s cognitive ability, daily living skills,

age and developmental status, nutritional status, skin integrity, medical

acuity, family dynamics and any potential for post discharge complications.

Delegates discharges to appropriate resources and ensures they coincide with

medical readiness.

Performs timely, professional and appropriate documentation in the electronic

medical records, discharge plan notes, and Case Management Software as outlined

in the COC departmental policy and procedures and as reflected in the Quality

Review Audit process.

Communicates closely with third party payors and the Business Office to ensure

all pertinent clinical information is provided to secure an authorization.

Appropriately documents information regarding the authorization number and the

approved length of stay on the Case Manager Software.

Serves as a resource to physicians for clinical management and financial

issues. Assists the Hospitalists with promoting efficiencies in the care

delivery system and reducing/ eliminating barriers to efficient/effective

service.

Promotes departmental goals of improved quality, improved patient outcome and

conserving resources as evidenced by value enhancement activities.

Analyzes the requirements of a variety of third party payors, using that

knowledge to create processes and systems which will meet the requirements.

Develops a cooperative, assistive relationship with on-site reviewers, working

to facilitate timely, positive responses for patient accounts.

Educates physicians, patients and staff with regard to payors, financial

issues, documentation, and potential compliance issues.

Reviews patient cases for potential problems with OIG Workplan Audits and

compliance issues. Reports problems and makes recommendation to appropriate

departments, such as Compliance.

Investigates and responds to billing concerns from Business Office, Health

Information Management, Admitting, and other sources. Resolves financial and

billing problems, such as appropriate patient status, correct payor source,

denials, appeals, and system issues.

Serves as an active member of committees, as needed, which may include a

variety of projects or topics.

Reviews medical records concurrently, with the expectation of 100% patient

review. Also conducts retro reviews as needed.

Serves as a patient advocate in locating resources, negotiating for coverage of

services, and resolving denials when medical necessity was present.

Enhances professional growth and development through participation in

educational programs, reading current literature, attending in-service meetings

and workshops that are related to assigned areas of responsibility.

Integrates

research findings into clinical practice.

Performs

other duties as assigned.

Qualifications

EDUCATION:

A minimum of an Associate Degree in

Nursing from an accredited nursing program is required. A Bachelor’s Degree in

Nursing from an accredited nursing program is preferred. Effective May 1, 2014,

all new-hire Associate Degree Registered Nurses (new graduate and experienced)

are required to start an approved BSN program within two years of hire and

complete an approved BSN program within five years of hire.

EXPERIENCE:

Must

have 2-3 years experience as an RN plus utilization management or discharge

planning/case management experience. Minimum two years experience performing

utilization review and/or quality assurance activities in an acute care

facility or HMO/PPO/PRO preferred. Must be able to adjust priorities quickly,

organize multiple tasks simultaneously, and work interdependently with many

levels of staff. Attention to detail; strong organizational, interpersonal and

communication skills; and innovative problem solving skills required. Must be

able to adjust work hours depending on depending upon departmental needs as

determined by the director or manager.

LICENSE & CERTIFICATION :

RN license in Kentucky required. Certification in a nursing specialty area or

CCM preferred.

  • For those hired after November 14, 2016,

KentuckyOne Health will verify education required by the position, through

primary source verification, prior to beginning employment. Education

verification will also include the collection of a high school diploma or

equivalent, transcript, or other written validation of education.

  • Effective May 1, 2014, all new-hire Associate

Degree Registered Nurses (new graduate and experienced) are required to start

an approved BSN program within two years of hire and complete an approved BSN

program within five years of hire.

AdditionalResponsibilities:

  • Demonstrates a commitment toservice, organization values and professionalism through appropriateconduct and demeanor at all times.

  • Adheres to and exhibits ourcore values: Reverence: Having a profound spirit of awe and respect for allcreation, shaping relationships to self, to one another and to God andacknowledging that we hold in trust all that has been given to us. Integrity: Moral wholeness, soundness, uprightness, honesty and sincerityas a basis of trustworthiness. Compassion: Feeling with others, being one with others in theirsorrows and joys, rooted in the sense of solidarity as members of thehuman community. Excellence: Outstanding achievement, merit, virtue; continually surpassingstandards to achieve/maintain quality.

  • Maintains confidentialityand protects sensitive data at all times.

  • Adheres to organizationaland department specific safety standards and guidelines.

  • Works collaboratively andsupports efforts of team members.

  • Demonstrates exceptionalcustomer service and interacts effectively with physicians, patients,residents, visitors, staff and the broader health care community.

Catholic HealthInitiatives and its organizations are Equal Opportunity Employers/CBKYONE

Job Nursing - RN

Primary Location KENTUCKY-LOUISVILLE-JEWISH HOSPITAL

Daily Schedule 3

Scheduled Hours per 2-week Pay Period 80

Weekends Required Occasional

Req ID: 2017-R0112286