SUMMARY OF THE JOB
Demonstrates the knowledge, critical thinking and judgment for nursing practice and performance based on ANA Nursing Scope of Practice and integrates the use of evidence-based outcomes for nursing practice; coordinates plan of care; provides education for patients, families and staff; and collaborates with all disciplines. Facilitates progress with the plan of care to assure discharge planning is completed on all patients; targeting complex care coordination by case manager and offering consultation to primary RN on discharge planning for the predictable and patternable patients as needed. Monitors patient progress and assures patient requirements are matched with appropriate resources. Partners with unit-based Social Worker to coordinate next site of care requirements for patient population and consultation with appropriate community agencies as needed.
The Case Manager must be able to demonstrate knowledge of growth and development to coordinate patient care appropriate to the age of patients served in his/her assigned clinical area. Employee must be able to successfully complete job specific orientation, Case Management specific competencies, and meet/exceed standards as identified in the criteria based performance appraisal.
ESSENTIAL FUNCTIONS AND RESPONSIBILITIES (50%)
Include the following, other duties may be assigned.
- Assesses the needs of the patient and family, when appropriate and coordinates, monitors, evaluates, and advocates for multiple services to meet the specific patient’s complex needs. Monitors quality and efficiency of progress and trends.
- Assessment is based on relevant physical, emotional, developmental, social, cultural, spiritual, and sexual data to identify needs and determine real and/ or potential patient risks. Assessments indicate knowledge and understanding of the complete medical plan of care including but not limited to treatment goals, orders, pertinent diagnostics and laboratory results, ancillary care plans, interventions, and discharge plans.
- Collaborates and communicates with multidisciplinary team members regarding patient needs based on assessment. Assessment process demonstrates individualization, clinical knowledge and judgment, critical thinking, prioritization, and patient centered care.
- Assessment identifies risk management and safety issues for each patient. Identifies and communicates risks to the multidisciplinary team members.
Plan of Care and Outcomes (5%)
- Analyzes assessment data to identify expected outcomes unique to the patient.
- Collaborates with physicians, patient, family, and health care team to develop and coordinate a plan of care, which enhances patient outcomes and supports the movement of the patient through the health care continuum.
- Collaborates with attending physician to discuss patient progress and achievement of day-to-day outcomes defined by evidence-based practice.
- Leads/facilitates team conferences and / or interdisciplinary rounds.
- Notifies and educates Social Worker and other disciplines of changes in condition, new information obtained appropriate level of care on discharge and discharge needs/concerns.
- Conforms to legal requirements, the state nurse practice act and the hospital/departmental policies and procedures.
- Advocates for adherence to appropriate evidence- based practice standards including Core Measures, by querying / prompting physicians and nursing to implement/order/document appropriately to support the severity of patient illness.
- Coordinates timely and comprehensive transition/discharge planning on all patients by care team members.
- Facilitates pre and post-hospital follow-up contact to include the physician, office staff, and referral agencies.
- Notifies patient/families of impending discharge date and plan as required by Medicare
- Delegate’s tasks and duties in the direction and coordination of care management team members, patient care staff, social work and precertification staff.
- Organizes job responsibilities and sets proprieties based on treatment team, patient needs.
- Demonstrates calming techniques and approaches with persons who are upset, angry, or disruptive. Takes steps to diffuse problematic situations. Involves Patient Relations as appropriate. Reports problematic situations to appropriate manager.
Evaluation of Patient Outcomes (5%)
- Consistently evaluates patient outcomes and revises the plan of care accordingly.
- Anticipates and identifies variances in the care process related to patient needs. Makes plans to resolve unexpected care requirements to facilitate the patient meeting optimum outcomes and moving through the health care continuum.
- Monitors, analyzes and communicates variance data.
- Participates in development of and review/revises case management tools, patient/family education tools and discharge instructions.
Utilization Review (10%)
- Monitors length of stay, resource utilization, quality of care, timeliness of service through comprehensive manual chart review, and discharge planning.
- Identifies patients at risk for readmission and implements effective transition/discharge plan to prevent unnecessary/unplanned readmission.
- Utilizes appropriate criteria to determine intensity of service and severity of illness in screening for medical necessity for admissions, appropriate patient class (bed status) and continued stays.
- Performs utilization review and reports information to third party payers for the purpose of certification of admissions and continued stay.
- Appropriately refers questionable admissions and extended stays to physician advisor.
- Monitors, reports and intervenes to avoid/appeal/reconcile denials of stay or care with third party payers.
- Reviews and manages appropriate resource consumption.
- Ensures the patients’ right to privacy and appropriate confidentiality with information about the patient is released to others.
- Documentation is accurate, timely, clinically relevant and for other team members to provide care/services in an efficient, continuous manner.
- Utilizes medical record appropriately.
- Accepts responsibility for and contributes to the success of core measures.
- Actively participates in increasing patient satisfaction score.
- Supports nursing shared governance activities for the pursuit of excellence in nursing care
- Identifies and communicates opportunities for improvement