Clinical Case Manager - Weekends
Company: Rutherford Regional Health System
Location: Rutherfordton
Posted on: April 26, 2024
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Job Description:
Rutherford Regional Health System is a 143-bed acute care
facility that offers a broad array of inpatient and outpatient
care. Rutherford Regional is dedicated to providing patients with a
full range of services to meet their healthcare needs. - We provide
our services in a caring, professional environment through the
teamwork of our medical staff and employees.Rutherford Regional
Health System's partnership with Duke LifePoint Healthcare is
bringing the pieces together to transform healthcare in Rutherford
County. Duke LifePoint Healthcare is a joint venture of Duke
University Health System, one of the country's leading academic
health systems, and LifePoint Health, a leading healthcare company
dedicated to Making Communities Healthier. These two forces joined
because of the shared interest in collaborating with hospitals,
healthcare providers and patients to bring high quality, innovative
healthcare services to communities. Duke LifePoint combines Duke's
unparalleled expertise in clinical excellence and quality care with
LifePoint's extensive resources and knowledge and experience
operating community hospitals and healthcare
organizations.Accountable for the execution, adaptation and outcome
of care management as prescribed in the initial Utilization Review
Plan with regard to resources, appropriateness of care and
adherence to a designated Geometric Length of Stay (GLOS) for each
patient.Essential Functions: -Assists with developing specific
departmental goals, standards, and objectives which directly
support the strategic plan and vision of the organization.Assesses
the quality of patient care delivered and coordinates patient care
services with patients, staff, physicians, and other
departments.Creates and fosters an environment that encourages
professional growth.Integrates evidence-based practices into
operations and clinical protocols.Works with physicians, nurses,
ancillary staff and social services at the point of care to
facilitate multi-disciplinary decision-making that is consistent
with the goals and objectives of the plan of care and the wishes of
both the patient and family.Must understand payer issues with
regard to patient management and resulting implications of clinical
decisions and anticipate to opportunities to reduce expense and
capture revenue appropriately from admission through
discharge.Coordinates care and services within the case managed
population.Educates Physicians and staff in Case Management
standards and assists them in meeting the regulations and standards
as requested by Joint Commission, OSHA, CMS, HCFA, AHCA and other
regulatory agencies. Educates and mentors all staff in UR standards
and LOS topics.Coordinates care and services within the case
managed population.1. Performs patient/family assessments on
admission to identify individualized care management needs.2.
Assists in identifying aspects of care for the patient/family that
require nursing knowledge and skills, and works with nursing staff
to plan strategies to meet care needs.3. Coordinates plan of care
and services, directing liaison activities to appropriately
integrate the patient into the health care continuum.4. Develop,
review, and revise care pathways for specifically identified DRG's
to meet regulatory requirements, reduce LOS, readmissions and
assure documentation meets Medicare requirements to reduce the risk
related to RAC's.5. Documentation in the medical records is
completed in the appropriate time frame and accurately reflects the
plan of care and CM interventions planned or completed.6. Advocates
for the patient and family throughout the entire episode of
care.Facilitates an interdisciplinary approach to patient care.1.
Participates in Interdisciplinary Team Meetings.2. Maintains
effective communications with all disciplines.3. Provides feedback
to the health care team verbally of via chart entries related to
the patient's progress toward reaching expected outcomes or about
barriers to the plan. Coordinates changes to the plan of care as
necessary.Educates Physicians and staff in Case Management
standards and assists them in meeting the regulations and standards
as requested by Joint Commission, OSHA, CMS, HCFA, AHCA, and other
regulatory agencies. Educates and mentors all staff in UR standards
and LOS topics.Insures effective Utilization Review Process.1.
Performs admission and concurrent medical record review.2.
Documents utilization review in accordance with departmental
guidelines.3. Facilitates physician documentation of data that
accurately reflects the patient's condition, co-morbidities,
treatment and procedures that support the most appropriate
admission status.4. Assists patients/families to ensure
understanding of third-party payer guidelines and financial
implications of discharge plans.5. Follows up with any denials
through the appeals process; including RAC chart audit
reviews.Emergency Department (ED) Case Management1. Serves as a
gatekeeper of patients being admitted to the hospital by
facilitating initiation of care starting.2. The ED Case Manager
starts initiation and utilization process, encouragement of use of
reimbursable diagnosis, interface with community agencies, creating
plans for high utilization patients, and referring patients to
other more appropriate areas of the hospital, i.e. outpatient.3.
The ED Case Manager is responsible for monitoring and managing
variances or elements of misuse of resources that may extend length
of stay.4. Communicates positively with physicians, nurse leaders
and ED staff.5. Actively observes the way patients enter into the
ED and the process of registration, triage, and documentation;
identifies the way the hospital places patients into the
appropriate level of care using the contributions of key
professionals.6. Ability to navigate through Meditech thus
producing an initial 1st Level Review using McKesson InterQual
Criteria to perform utilization management and quality screening
for assigned patients.7. Addresses/resolves system problems
impeding diagnostic or treatment progress. Proactively identifies
and resolves delays and obstacles to discharge.8. Seeks
consultation from appropriate disciplines/departments as required
to expedite care and facilitate discharge.9. Utilizes advanced
conflict resolution skills as necessary to ensure timely resolution
of issues.10. Applies approved utilization acuity criteria to
monitor appropriateness of admission and continued stays, and
documents findings based on Department Standards.11. Identifies
at-risk populations using approved screening tool and follows
established reporting procedures.12. Refers cases and issues to
Physician Advisor in compliance with Department procedures and
follows up as indicated.13. Discusses payer criteria and issues on
a case-by-case basis with clinical staff understanding of 3rd party
payer guidelines.14. Manages all aspects of discharge planning for
assigned patients in coordination with the Social Worker.15.
Initiates and facilitates referrals for home health care, hospice,
medical equipment and supplies.16. Facilitates transfer to other
facilities for targeted patient population.Minimum
EducationAssociates Degree in Nursing requiredBachelor's Degree in
Nursing preferred.Required SkillsCertifications:BLS requiredACMA
Certification highly preferredCCM Certification highly
preferredRequires critical thinking skills, decisive judgment and
the ability to work with minimal supervision. Must be able to work
in a stressful environment and take appropriate action.Licenses:
Current RN license to practice in NC (NC licensure or multi-state
(compact) license).
Keywords: Rutherford Regional Health System, Spartanburg , Clinical Case Manager - Weekends, Healthcare , Rutherfordton, South Carolina
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