Frisbie Memorial Hospital
Rochester, NH, USA
Patient Population Served:The RN Case Manager may work or works with the child, adolescent, adult and/or geriatric patient.
Essential Position Functions:1. Facilitates and Coordinates Care and Services.Communicates/collaborates with all members of the health care team, including the interdisciplinary team (e.g., physicians, nursing, SW, PT. OT, ST, nutrition, etc.), patients, physician practices, community agencies, and payors regarding patient needs, plan, and transition. Considers patient needs to include medical, physical, psychosocial, spiritual, financial , cultural and emotional aspects.Facilitates or participates in ad hoc patient/family conferences and with interdisciplinary team designed to gather information, identify barriers or problems, and to resolve issues around in-hospital and post-hospital care.Educates health team colleagues about care management, including the role of the care manager. Participates in other educational programs as requested/appropriate.Assists with explanation and obtaining Advance Directives.May collect, analyze, enter and report care management data related to patient care and participates in continuing quality improvement.Maintains appropriate documentation.
2. Performs Discharge Planning.Identifies discharge planning needs through chart review, patient interview, discussion with other caregivers and/or exchange of information at multi disciplinary patient care rounds.Considers impact of disease process and other barriers.Develops discharge plan A and B and communicates with patients and other caregivers as appropriate. Communicates with external case managers and other post discharge providers as appropriate.Facilitates referral/transfer/discharge of patient to another level of care, health professional or setting.Coordinates home IV/enteral and home health referrals, etc. Ensures that oxygen and DME ordered by other departments will be / is delivered timely to meet the patient's needs.Refers to and collaborates with community at large to develop and implement plans for complex cases which require multi-agency involvement.Maintains appropriate documentation.
3. Performs Utilization ReviewReviews patient medical records for appropriateness of admission and/or continued stay using established criteria. Communicates utilization issues to physician, nursing staff, social workers, business office or patient registration staff, and other appropriate persons.Refers cases for physician review (internal or external review) as appropriate. Coordinates and performs all follow up activities related to Medicare other third party payors, and hospital-negotiated contracts.Assists medical staff in responding to appeals.Provides requested information regarding patient care and services to external review and regulatory agencies.Communicates with patients, physicians and nurses changes in review findings resulting in level of care changes and/or findings consistent with termination/denial of benefits. Delivers HINN letters when appropriate. Provides instruction/education to patients/families regarding appeals process upon receipt of Medicare HINN / termination of benefits letter.Collaborates with managers and staff in the Patient Registration, Patient Accounts and HIM Departments on issues of continued stay, denials and related activities. Serves as a resource for same.Monitors for utilization, quality of care, risk and infection control issues. Reports as needed. Keeps Program Director, Care Coordination, Clinical and Fiscal Integration informed on matters which require notification or administrative action.Discusses cases with attending physician. Explores and implements strategies to reduce LOS when appropriate and to optimize resource consumption.Maintains appropriate documentation. Ensures the security/confidentiality of patient information.
4. Assists with Patient Rights/GrievancesResponds as needed to patient grievances regarding medical necessity, appropriateness or quality of care.Reviews with patient his/her right to file a grievance, when applicable, directly with the Medicare Quality Improvement Organization (QIO). If requested, Care Manager will assist the patient (or representatives) in complying with Medicare Grievance process.
Non-Essential Position Functions:Participates as appropriate and is knowledgeable in fire safety, disaster, infection control and all appropriate hospital programs.
Performs other duties as needed or as judgment dictates.
Position Qualifications:Education Required: Current and unrestricted NH RN license required. Bachelors Degree preferred.Experience: 3-5 years recent acute hospital experience as RN, prior discharge planning experience helpfulCertification: Case Management Certification desired