Case Manager-6027

Staff Position Description

Position Title: Case Manager Position Code: CaseMgr-____

Department: Case Management / Behavioral Health Safety Sensitive: YES

Reports to: Manager/Director Exempt Status: YES

Position Purpose:

All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision to be among the kindest, highest quality health systems in the country.

This position provides support to the patients and their families served at KHI. The scope of responsibilities includes coordinating, providing, and maintaining activities to meet the needs of the patients and their families from adult to geriatric.

Key Responsibilities [List of material responsibilities and essentials duties which must be completed in achieving the objectives of the position]

Collaborates with Physicians, Nurses, Social Workers, and other hospital departments as necessary, to facilitate the improvement in the quality of care and/or the efficiency with which hospital services are utilized. Ensures the active involvement of the patient and or family in the evaluation process and provides assistance with planning and arranging post hospital services. Identifies appropriate community resources for each assigned patient and works collaboratively with patients, families, multidisciplinary team members and community agencies to achieve desired patient outcomes. Ensures initial implementation of the discharge plan and appropriate education regarding discharge plan to patient and family to facilitate a safe transition of care from the hospital to home or another facility. Performs Utilization Review (UR) to determine medical necessity for admission, continued stay, appropriate utilization of resources and level of care determination based upon MCG criteria. Communicates medical necessity information with the requesting Payers, as per KHI policies and procedures. In conjunction with the Discharge Care Coordinator, determines whether required post discharge services are covered by the patient’s payer and informs patient of coverage determinations. Maintains accurate and timely documentation of patient assessments, continuing reassessments, and discharge plans.

Unit Specific Responsibilities

In-Patient Case Management

Review Process

· Conducts assessment and evaluation of admitted patients for medical, physical, and psychological factors that may contribute to their disease process and may require specific or complex continuing care and/or supportive services.

· Reviews medical records concurrently and retrospectively as necessary to assess the management of cases by comparing progress to predetermined criteria.

· Evaluates for medical necessity, level of care, coverage issues, appropriate utilization of resources, and planning by reviewing physician documentation to ensure that MCG criteria is met.

· Collaborates with members of the healthcare team concerning patient’s assessment, goals, care plan and progress.

· Performs ongoing assessments of patients for continuing care needs such as, Skilled Nursing Facilities (SNF’s), acute Long Term Care Facilities, Durable Medical Equipment (DME), and Home Health.

Discharge Planning/Quality of Care

· Participates in Multidisciplinary Rounds (MDR) to assist with the development of care plans that will meet the patient’s current and continuing healthcare needs.

· Serves as an advocate for the patient and protects patient right’s as they pertain to the ethical and legal issues of confidentiality during the case management process.

· Based on patient assessment, develops a discharge plan, per KHI’s Discharge Planning policy, to coordinate the provision of goods and services with referrals to specific providers, and ensures initial implementation of the discharge plan in collaboration with the Discharge Care Coordinator.

· Based on patient’s assessment and collaboration with the healthcare team, and the patient/family, the Case Manager develops and documents the discharge plan by identifying the needs of the patient and the availability of resources to ensure a safe transition from the hospital. The Case Manager assists patients and their families with needs, such as complex discharge planning needs, suspected emotional, cognitive, or mental problems, financial issues, and home/environmental issues. When identified, refers all suspected child and elder abuse/neglect concern to the appropriate agency.

· Participates in MDR to ensure effective communication and collaboration for patients identified as having complex needs.

Utilization

· When necessary, determines which cases will require medical staff review and/or UR management intervention based upon KHI’s Utilization Management Plan. Factors such as cost/benefit, appropriateness, availability of resources, quality, prior authorization requirements, and patient choice are taken into consideration during the case management process.

· Communicates with the attending physician, expected length of stay, Medicare guidelines and individual variances.

· Proficiently utilizes MCG and applies clinical guidelines and criteria appropriately to make utilization determinations. Inputs data into MCG when needed. Communicates frequently with the UR Nurse and provides requested data timely.

Compliance

· Participates in committees, performance improvement activities, mandatory in-services, and continuing education.

· Maintains compliance with established hospital policies, procedures, objectives, safety, environmental and infection control guidelines.

ED Case Manager

In collaboration with Emergency Department (ED) providers, screens patients to identify those that require admission with identification of appropriate level of status assignment, those that do not require admission, and those with multiple presentations to the ED who may require intervention to avoid future unnecessary ED visits. In addition, the ED Case Manager ensures the unit base Case Managers have the appropriate information when the patient is admitted.

· Completes initial UR review on 100% of patients admitted during scheduled shift and completes all data entry into required documentation tools prior to end of shift.

· Assists with appropriate compliance of regulatory requirements, both State and Federal, including delivery of Hospital Initiated Notices of Non-coverage (HINN).

· Reviews non-emergent transfers into the hospital for medical necessity of admission.

· Provides physicians with alternatives to admission when patients do not meet medical necessity guidelines for admission to the facility.

Pre-Access Case Manager

The Pre-Access Case Manager screens direct or scheduled admissions for appropriateness of admission and facilitates placement to the appropriate level of care for both scheduled admissions and transfers of care. The Pre-Access Case Manager intervenes as necessary when criteria are not met. In addition, the Pre-Access Case Manager initiates UR documentation for those patients that have been screened but will be followed by the unit-based Case Managers. The Pre-Access Case Manager may provide ongoing support and expertise to the healthcare team. This collaborative process requires communication and coordination with the referring physician, staffing office, and payors. The Pre-Access Case Manager is responsible for assisting in maintaining a financially stable department, promoting their own professional development with an emphasis on evidence-based practice and education.

· Reviews surgery and OP procedure schedules to verify appropriate planned status assignment

· Intervenes with Physician and Physician Office staff to address any procedure planned for a status not meeting level of care guidelines (e.g., Medicare IP Only procedures)

· Maintains current knowledge related to payor guidelines in reference to certification/authorization, ensuring payment for admission.

· Pre-screens direct admissions and facilitates physician to physician discussion

· Identifies scheduled admissions and transfers not meeting level of care criteria and communicates concerns to the Physician Advisor and/or our external review organization as indicated.

· Communicates process or physician related concerns to the Director and/or Physician Advisor immediately when identified.

· Verifies that the patient’s insurance has approved admission before accepting non-emergent patients from another facility.

· Determines and communicates the appropriate patient status to the admitting department as applicable.

· Communicates pending transfer cases to the appropriate case manager.

Physician Services

· Collaborates with the interdisciplinary team members (including physicians, providers, licensed mental health practitioners, case managers, nurses, and other members of the care team) to ensure comprehensive care for at-risk patients identified.

· Conducts assessments of and identifies patient’s medical needs and social needs by interviewing patients, family members, and reviewing medical record documentation.

· Works with patients, families, and teams to draft service plans, review case progress and determine case closure with the provider team.

· Works with patient to achieve wellness goals and autonomy.

· Identifies and assists patients requiring assistance with eligibility determination for insurance, vocational programs, other social programs, and funding sources.

· Connects patients and families with the necessary services identified, in Mohave County and beyond.

· Maintains a current working knowledge of services available and a relationship with the local community, particularly services available to patients with limited or non-existent payment resources.

· Serves as a resource person and provides counseling resources for overall health.

· Advocates for patient and family empowerment and independence to make autonomous health care decisions and to access needed services within the healthcare system

· Provides education/consultation to staff to ensure achievement of quality patient outcomes and patient satisfaction

· Proactively acts as a liaison between the patient, family, medical staff, nursing staff, ancillary personnel and agencies involved in the patient throughout the continuum of care.

· Participates in discharge planning activities for complex patients assigned when in a higher level of care to ensure a timely discharge and to provide appropriate linkage with post-discharge care providers

· Maintains accurate and timely records, including clinical and progress notes, according to designated policy and procedure

· Participates in staff meetings and supervisions in areas assigned to assure a team approach

· Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency and serves as a preceptor and resource to less experienced staff

· Actively supports department-based goals, which contribute to the success of the organization

· Protects Patient Rights as they pertain to the ethical and legal issues of confidentiality during the case management process.

· Stays up to date on current best practices.

· Participates in designated Quality and Process Improvement initiatives.

· Ensures all tasks completed are compliant with all Federal, State, organizational, and departmental policies, and regulations.

· Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to the mission and vision of KHI

All locations:

Professional and Community Relations

· Identify and nurture referral sources. Set up meetings, contacting resource from surrounding providers, and setting up meetings to build rapport.

· Maintain effective communication with patients, families, referral sources, clients, and team members.

· Work in coordination with KRMC’s Public Relations/Marketing Department.

· Develops and implements activities intended to educate and inform professionals, and the community, of KHI’s concern for the health and well-being of the community.

Additional Duties

· Participate in committees, performance improvement activities, mandatory in-services, and continuing education.

· Maintains compliance with established policies, procedures, objectives, safety, and infection control guidelines.

· Attends community health fairs; both KHI sponsored or community sponsored.

· Performs additional duties as requested.

Qualifications [Statements regarding minimum educational and experience qualifications, required proficiencies with specialized knowledge, computer proficiencies, military service, required certifications, etc.]

Education: Associate Degree in Nursing, graduate of a Nursing diploma program, or Bachelor’s Degree in related health/behavior/social science field.

Experience: N/A

Certification: N/A

License:

· RN’s must hold current and valid Arizona RN license or compact state RN license.

· Current and valid Arizona driver’s license.

Knowledge, Skills, and Abilities:

· Must have knowledge of clinical, social, insurance/finance and physical factors that must be considered when evaluating how a patient’s expected treatment plan can be met.

· Must have knowledge of clinical and social factors that may affect the patient’s functional status during treatment regimen.

· Knowledge of community resources to meet clinical and social needs.

· Possesses excellent interpersonal communication and negotiation skills in interactions with patients, families, physicians, and health care team colleagues.

· Ability to work with people of all social, economic, and cultural backgrounds; be flexible, openminded, and adaptable to change.

· Demonstrates the ability to connect patients and families with necessary services, both inside and outside of Kingman area.

Unit Specific Requirements:

Physician Services:

· License:

· LCSW; ACM; CCM; LBSW; LMSW; CNS, APRN

· Licensed by the appropriate Arizona State Board according to license

· Certifications:

· BLS certified through American Heart Association (AHA) or American Red Cross

· Level One Fingerprint Clearance Card

Preferences [Preferred attributes for the position which are not absolutely required in the minimum qualifications (i.e., multi-lingual, master’s degree)]

Experience:

· One year in Outpatient setting.

· Experience in case management, discharge planning, quality improvement, and/or marketing.

Special Position Requirements [Optional section: any travel, security, risk, hazard, or related special conditions which apply to the position]

Exposure Categories:

· Category II: Expected duties have possible, but not routine, potential for exposure to blood, body fluids or tissues

· Other Potential Hazard(s): Possible exposure to hostile individuals

Work Requirements [Optional section: work requirements for physical or other important issues which relate to the job]

· Ability to handle multiple priorities simultaneously.

· Able to demonstrate effective, positive oral and written communication skills.

· Computer skills: Ability to work within an EMR system, Word, and Outlook.

· Ability to utilize technical business equipment (i.e., phone, fax, computer, scanner, etc.).

· Ability to sit for 3-5 hours per day.

· Ability to stand for 3-5 hours per day.

· Ability to walk for 3-5 hours per day.

· Able to demonstrate effective, positive oral and written communication skills.

· Will require travel to KHI Practices and Facilities.

Date Staff Position Description Created / Revised: 3/02/2023