Nurse Case Manager
MercyOne
1 Positions
ID: TRHEUS00425553MERCYO
Posted On 05/22/2023
Job Overview
Employment Type:
Part time
Shift:
Description:
The case manager coordinates care across an episode and/or the continuum for clients with complex problems and diverse needs. The case manager’s focus is to maintain patients at an optimal level of health and to support self-care. Case managers collaborate with physicians, social services, nurses and community agencies to define care options and resources, to plan cost effective quality care and to achieve optimal outcomes.
Specific responsibilities include case screening, insurance approval, assurance of timely services, and facilitation of discharge with transition to the appropriate services. Patient outcomes are achieved through effective application of care plans, managed care concepts, appropriateness criteria, resource management, knowledge of community resources, and collaboration with other clinical disciplines. She/he works proactively to coordinate the services of physicians, nurses, and other disciplines to effectively prepare patients for discharge.
The case manager facilitates program development, efficient care delivery processes and quality improvement including tracking of resource utilization and outcome measures. The case manager is accountable for improving service through the use of cost and quality outcome data, current clinical practices and related research, regulatory requirements, and comparative benchmark opportunities.
Customers include patients, families/visitors, physicians, physician assistants, nurse practitioners, case managers, representatives of third-party payers, representative of referring agencies, interdepartmental and intradepartmental staff, vendors, and volunteers.
ESSENTIAL FUNCTIONS:
1. Adheres to the principles of caring and expected behaviors outlined in Mercy Medical Center's Model of Caring and Trinity Health's Code of Conduct, fostering a climate where all customers are treated in a manner consistent with Mercy Medical Center's Mission and Values.
2. Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health’s Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
3. Performs other duties consistent with purpose of job as directed.
SKILLS AND ABILITIES REQUIRED:
1. Maintains a professional, collaborative work environment so as to foster a positive public image for Mercy Medical Center.
2. Knows and adheres to all laws and regulations pertaining to patient health, safety, and medical information (i.e., HIPAA, Stark, etc.).
3. Exhibits sound judgment, critical thinking, problem solving and decision-making skills.
1. Demonstrates the ability to work independently, and the ability to work collaboratively in a team environment.
2. Communicates effectively with patients, significant others, and members of the health care team.
3. Compiles information; keeps records, prepares, or directs preparation of reports and correspondence.
4. Executes daily utilization functions for assigned patients, including prior authorization, admission, precertification/certification/recertification, concurrent and retrospective review, associated analysis, and referral appropriateness.
5. Participates in comprehensive team meetings and conferences regarding specific patient needs that affect cost, quality, and length of stay. Demonstrates ability to promote collaboration and creativity among members of the health care team.
6. Responsible for assuring thorough case management assessment, as well as early and ongoing discharge plans by collaborating with patients, families, physician, payors, and providers across the continuum of care. Proactive in making arrangements for discharge.
7. Reports potential catastrophic and high-cost cases to department director, nursing director, and finance department for appropriate medical/administrative review and management.
8. Effectively manages length of stay and cost avoidance.
9. Serves “Important Message from Medicare-to-Medicare patients. Serves denials for continued stay to patients or DPOA/guardian when patient stays do not meet screening criteria or second level of review, and patient refuses discharge. Assures adherence to Medicare regulations as appropriate, regarding patients’ rights to appeal discharge.
10. Works with the patient’s physicians, to appeal denials from Iowa Foundation for Medical Care and other insurance companies as appropriate.
11. Discuss cases with Utilization Review Committee and/or Executive Health Resources (EHR) when cases fail to meet admission, treatment, length of stay and/or discharge standards.
12. Attends meetings of the Utilization Review Committee and submits reports as required. Participates in the development of a written plan that describes the Utilization Review Program.
13. Applies quality improvement methods and techniques to improve case management processes to maximize cost and quality benefits for Mercy Medical Center.
14. Demonstrates general knowledge of computers. Demonstrates specific knowledge related to software programs such as Cerner/PowerChart, HealthQuest, Milliman Guidelines, and other appropriate software programs used in the course of case management processes.
15. Performs other duties consistent with the purpose of the job as directed.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS:
1. During an 8-hour day, an employee must be able to stand/walk for 6 hours and sit 2 hours.
2. Job requires occasional (6-10% of work time) squatting, crawling, crouching, kneeling, and balancing; frequent (21-50% of work time) bending, stooping, reaching above shoulder level, pushing, and pulling.
3. Job requires the ability to frequently (21-50% of work time) lift and carry objects weighing approximately 11-24 pounds.
4. Job requires exposure to marked changes in temperature and humidity and may be exposed to infectious disease, hazardous waste, and chemicals.
5. Must have fine motor and manual dexterity skills to grip and manipulate items and perform repetitive action such as computer entry.
6. Must be able to see at a near visual acuity level; able to speak and hear speech.
7. Job requires high level of mental concentration to attain established deadlines. Working environments includes frequent interruptions.
8. Must adhere to applicable organizational requirements on an annual basis for Employee Health Directives.
MINIMUM EDUCATION, LICENSURE, CERTIFICATION, AND EXPERIENCE REQUIRED:
1. BSN required.
2. Current RN license to practice nursing in the state where case management services are administered. Certification in the area of case management is preferred.
3. Three to five years’ clinical experience required. Clinical competency in the case management of targeted population is desirable.
4. Broad-based health care operational experience preferred.
5. Child and Dependent Adult Abuse Mandatory Reporter Training is required within 6 months of hire and every 5 years thereafter.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.