SpartanburgRecruiter Since 2001
the smart solution for Spartanburg jobs

Clinical Case Manager

Company: Rutherford Regional Health System
Location: Rutherfordton
Posted on: May 11, 2024

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).Computer: Microsoft Office - Excel, MeditechMinimum Work Experience1-3 years case management experience preferred.Benefits - Wide range of benefits options!Here at Rutherford Regional, you choose your own Medical, Dental, and Vision plans from a variety of competitive options that give you the coverage that best fits your needs.HSA401(K) retirement plan contributions

Keywords: Rutherford Regional Health System, Spartanburg , Clinical Case Manager, Healthcare , Rutherfordton, South Carolina

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category

Log In or Create An Account

Get the latest South Carolina jobs by following @recnetSC on Twitter!

Spartanburg RSS job feeds