PRIMARY FUNCTION:

Oversees the utilization of healthcare resources, including discharge planning to facilitate the achievement of clinical, quality, financial and patient satisfaction goals.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

UTILIZATION MANAGEMENT:

Reviews the admission assessment, collaborates with primary nurse and other health care providers to ensure a multidisciplinary plan-of-care is in place to meet identified patient care needs and desired outcomes.

Identifies system issues that serve as barriers to care. Participates in development and implementation of strategies to remove barriers and facilitate performance improvement measures.

Monitors efficiencies in scheduling diagnostic procedures and coordination of treatments to facilitate achievement of effective clinical, fiscal, quality, and patient satisfaction goals.

Participates in multi-disciplinary team rounds on the assigned unit.

Identifies need for patient to be evaluated by other members of the health care team and takes appropriate action to facilitate.

Collaborates with the unit medical director and/or physician advisor to facilitate achievement of clinical, quality, financial, and patient satisfaction goals.

Communicates and secures continued stay authorizations with Managed Care Organizations.

CASE MANAGEMENT:

Identifies patients who have post-acute care, placement, and complex discharge planning needs based on a comprehensive assessment that includes physical, as well as psycho-social factors/needs.

Anticipates, initiates, and establishes a discharge plan for patients with post acute care needs, collaborating with the physician, nurse and other health care providers, the patient, their family/primary caregiver(s), third-party payers, and employer in accordance with established clinical guidelines, standards, and pathways.

Communicates patient needs and arranges services with appropriate resources after securing patient consent and choice of vendor.

Takes ownership of the discharge process to expeditiously return the patient to the most appropriate post-acute care setting.

Establishes time specific objectives, goals, and actions in conjunction with the patient and family, to meet identified needs.

Builds trusting relationships with internal and external customers, i.e., physicians, nurses, patients and their families, vendors, payers, etc.

Organizes, secures, monitors, and modifies the resources necessary to meet the goals stated in the case management plan. The Case Manager confirms the continuation of patient care services across the continuum via phone follow-up with patients/family to ensure the discharge plan has been executed.

Alerts social work of all patients with potential placement needs and works to facilitate the provision of care in the most appropriate care setting.

Serves an s an expert consultant to members of the health care team and works closely with assigned units to meet LOS expectations.

Manages and accurately documents pertinent patient and case management data in MIDAS+, including but not limited to URE, URSE, URAD and URDP.

Assumes responsibility for professional growth, shares knowledge with co-workers and health care team members.

Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, and unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients or visitors.

Performs other related duties as required.

EDUCATIONAL/LEADERSHIP REQUIREMENTS:

Completes a minimum of 8 continuing education credits (CEU'S) per year in Utilization and/or Case Management.

Demonstrates on-going commitment to the department by serving as a preceptor, providing inservice and/or educational presentations annually, and participating in unit-based PI initiatives to include organizational and regulatory monitors and/or measurements. Actively participates in department operational planning work groups.

Demonstrates commitment and leadership in specialty through membership in professional organizations such as CMSA, ACMA, etc. attending meetings at a minimum on an annual basis and sharing updates with colleagues.

EDUCATION AND EXPERIENCE REQUIREMENTS:

Registered Nurse with BSN required within 3 years of hire and Maryland or Compact State RN Licensure. Related work experience in Utilization Management, Case Management and or Home Care.

Maintain documented hours of relevant continuing education related to licensure requirements. Some continuing education should be related to role enhancement and changes of clinical practice within assigned area.

SPECIAL REQUIREMENTS:

• Active MD/Compact state RN Licensure, in good standing.
• Current BLS
• Case Management Certification (CCM) required within 18 months of eligibility.