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DescriptionGENERAL SUMMARY AND SCOPE:Under the supervision of the Director, this position is responsible for the implementation of the Case Management process. Monitors physician documentation and works closely with the medical staff for appropriateness of hospitalization. Identify potential risk management and utilization issues and reports findings per departmental protocol. This position is responsible for initial utilization and discharge assessment and completes concurrent utilization review and monitor progress through the acute care continuum. Works closely with the Social Worker in the identification of discharge and transition needs and is ultimately responsible for the coordination of discharge planning activities. This is accomplished by working collaboratively with interdisciplinary staff internal and external to the organization. Works closely with Clinical Documentation Specialist in supporting documentation needs. Participates in quality improvement and evaluation process.ESSENTIAL TASKS, DUTIES AND RESPONSIBILITIES
Makes patient rounds with and without physician to evaluate and assess the needs of the patient, assigning a designated level of risk of identified barriers to plan of care and discharge/transition needs.
Reviews the medical records daily to complete utilization review documenting Admission Justification and Ongoing Plan of Care.
Arranges for facility cooperation in the performance of the delivery of care and awareness of psychosocial needs for resolution of individual cases.
Interviews patients, family members, and significant others to summarize immediate level of comfort and pending problems that present as a deterrent to delivery of care.
Acts as a liaison between patient, family, significant other, and hospital staff during periods of crisis.
Communicates with nursing and medical staff in assessing the psychosocial needs of the patient to monitor and oversee the discharge plan.
Communicates with patients, family, significant others in identifying the discharge need of the patient and any barriers in the completion of a safe discharge goal.
Maintains current working knowledge of HFAP, COBRA, EMTALA, OSHA and other regulatory standards.
Maintains current, accurate documentation in the patient's medical record.
Maintains current and accurate data collection related to the quality of the delivery of care of the department.
Works closely with the Social Worker in assigning tasks and responsibilities in the discharge planning process
Maintains a working knowledge of and update community resources in areas of practice.
Participates in reporting abuse, neglect or exploitation suspected prior to hospitalization as indicated by hospital protocol. Report findings to the appropriate agency.
Works closely with the Clinical Documentation Specialist to identify and update the working DRG as indicated by patient acuity.
Contacts attending physicians as needed to ensure patient medical information documented in medical record meets quality, and appropriate reimbursement.
Coordinates in an interdisciplinary manner with medical and nursing personnel to clarify patient’s medical status needs and coordinating plans for discharge/transition from the acute care setting. This process is supported by current research and evidence-based practice.
In reviewing medical record documentation, communicates with the attending physicians as needed to ensure the documentation represents the acuity of need of that patient to allow for appropriate reimbursement.
Contacts attending physician to clarify patient’s medical information and discharge plans and identify potential needs.
Directly responsible for referral of services indicated or required by the patient post-discharge, (i.e. SNF, Home Health Care).
Assures all high risk and/or complex patients have an interim plan of discharge established prior to discharge from our facility.
Proposes alternative placement and/or treatment options as appropriate to facilitate and ensure a cost efficient plan of care and quality outcomes.
Collects appropriate avoidable delays and other data as directed.
OTHER TASKS, DUTIES AND RESPONSIBILITIES
Responsible for referring patients with special financial needs and/or requirements to the appropriate finance personnel.
Contacts attending physician to clarify patient’s medical information and discharge plans and identify potential needs.
Identifies clinical or system/process breakdowns and improvement opportunities and documents according to the PI plan.
Intervenes and recommends appropriate referral to resolve system/clinical barriers to patient progression, collaborating with other disciplines as appropriate.
Assures compliance with regulatory standards of care both at the state and federal level.
Assesses all patients or potential risk management and quality issues through appropriate intervention or referral.
Abstracts, tracks and trends data related to resource utilization, avoidable tests/procedures, case management interventions, etc.
Initiates referrals to Ethics Committee, Physician Advisor, QA, Risk Management or legal services as appropriate.
Assists Social Worker in the initiation of advanced directives or provides resources as needed to educate patient/family.
Demonstrates professional accountability through supporting patient’s rights, informed consent and advanced directives.
Identifies patients/families in need of grief or crisis intervention and makes referrals as indicated.
Collaborates with physicians on appropriate clinical documentation to accurately reflect severity of patients’ illness.
Reinforces education with patient/family on plan of care, discharge instructions, follow up, and expected outcomes.
Provides education for team members regarding appropriate utilization of services and levels of care indicated by the clinical situation.
Actively participates in the education of healthcare team members on current healthcare economic issues impacting proactive patterns, reimbursement and positive patient outcomes.
Educates patients and families regarding community resources, access to routine health care, and health maintenance.
Participates in department performance improvement activities as assigned and attends required training.
KNOWLEDGE, SKILLS, AND ABILITIES
Registered Nurse, Licensed Social Worker (LSW) or Licensed Independent Social Worker (LISW). License must be active and valid in the State of Ohio.
Three to five years’ experience in an acute care hospital setting.
Experience with case management process.
Certification in a field related to Case Management preferred.
Equal Opportunity Employer/Protected Veterans/Individuals with DisabilitiesThe contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information.
