Hamilton Health Care System

The case manager understands financial implications of care in todays healthcare environment such as (but not limited to): requirements for prior approval by payer; cases which would benefit from alternative care; analysis of necessary medical services for cost containment; healthcare plans for appropriateness; home health/hospice resources; healthcare delivery systems; DRG system; care mix index; managed care and capitation.. Responsibilities also include facilitating the admission process for non-elective, emergency inpatient admissions and outpatient observation stays; monitoring observation stays at the end of 23 hours for possible inpatient admission or discharge planning; ensuring that all patients are screened against Interqual/Milliman or other appropriate criteria and assist the physician in identifying alternative methods of care when criteria are not met.. Provides simple discharge planning services, such as Home Health and DME referrals and makes referrals to social workers for complex discharge planning.. The case manager will assist in program development and implementation for specific programs and plans of patient care such as clinical pathway, population specific and disease management initiatives.. Works in a typical acute health care setting with adult, geriatric, newborn, special care nurseries, pediatric patients and families experiencing a wide range of medical and/or surgical problems.

complex case manager

JOB SUMMARYPractices with minimum supervision from another licensed professional and is able to perform the following components of case management according to the Case Management Society of America Standards: assessment, facilitating, planning, advocating, , monitoring, evaluation, and outcomes.. In collaboration with all healthcare professionals involved, this position is also able to demonstrate the above components within the following core activities: coordination and service delivery, physical and psychological factors, benefit systems, cost benefit systems, cost benefit analysis, case management concepts and community resources.The case manager facilitates communication and coordinates between all members of the healthcare team involving the patient and family in the decision-making process in order to minimize the fragmentation of the healthcare delivery system.The case manager is a leader in effecting change to improve the quality of patient care and reduce the cost of services on a care by care basis.The case manager understands financial implications of care in todays healthcare environment such as (but not limited to): requirements for prior approval by payer; cases which would benefit from alternative care; analysis of necessary medical services for cost containment; healthcare plans for appropriateness; home health/hospice resources; healthcare delivery systems; DRG system; care mix index; managed care and capitation.Responsibilities also include facilitating the admission process for non-elective, emergency inpatient admissions and outpatient observation stays; monitoring observation stays at the end of 23 hours for possible inpatient admission or discharge planning; ensuring that all patients are screened against Interqual/Milliman or other appropriate criteria and assist the physician in identifying alternative methods of care when criteria are not met. Works closely with the Physician Advisor on cases that do not meet admission criteria or continued stay criteria. Provides simple discharge planning services, such as Home Health and DME referrals and makes referrals to social workers for complex discharge planning. The case manager and social worker will work in collaboration as a team to ensure timely provision of services. The case manager will be responsible for identifying performance improvement opportunities and assist with data collection. The case manager will assist in program development and implementation for specific programs and plans of patient care such as clinical pathway, population specific and disease management initiatives. The case manager will coordinate the care of an average case load of 25 patients per day.QualificationsJOB QUALIFICATIONSEducation: Graduate of an accredited School of Nursing.Licensure: Current RN Nursing license in the State of Georgia. AHA BLS CPR required.Certification: Certification in Case Management is desired or must be obtained as soon as eligible to sit for examination.Experience: Five years of nursing experience as a RN with two years of recent clinical experience. Utilization Review experience of at least one year is preferred. Computer skills experience and basic knowledge of statistics is preferred.Skills and Personal Qualities:* Knowledge of all phases of the nursing process and case management process.* Must demonstrate clinical knowledge in patient care as well as qualities of sound judgment.* Skilled in the art of human relations, problem solving and conflict resolution/negotiation.* Ability to articulate knowledge to others.* Demonstrates good role model qualities, ability to effectively interpret, implement, and support approved hospital policies, regulations, philosophy and objectives.* Is self-directed in maintaining and improving own knowledge in clinical skills as well as cognitive aspects of patient care, nursing theory, current research and case management.* Capable of effecting positive change across all departments to improve the quality of patient care and reduce the cost of services.* Ability to do 1:1 and group teaching.* Ability to maintain a strong relationship with the medical staff and work as partners to facilitate his/her practice.* Knowledge of Medicare, Medicaid and third-party reimbursement policies and procedures.* Knowledge of computer hardware and software applications used in the department.PHYSICAL, MENTAL, ENVIRONMENTAL AND WORKING CONDITIONSWorks in a typical acute health care setting with adult, geriatric, newborn, special care nurseries, pediatric patients and families experiencing a wide range of medical and/or surgical problems. Requires flexible work schedule to include weekends, holidays and evening hours as needed to meet patient needs. Requires ability to lift and turn patients. Manual and finger dexterity and eye-hand coordination is necessary. Requires standing and walking for extensive periods of time. Requires corrected vision and hearing to normal range. Requires working under stressful conditions. Requires exposure to communicable diseases or body fluids. Requires working with computers. Requires prolonged periods of time spent on the telephone.

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