While the various roles of the RN-Case Manager (RN-CM) fall under the same job code, each RN-CM works primarily in one of three functions: Bed Control, Utilization Review, or Discharge Planning. While the RN-CM may serve in one of these focused areas, the RN-CM may be asked to move to various areas of focus as deemed necessary by the needs of the department. The three areas of focus are detailed below:Bed Control - Participates in the coordination of care and service of a patient population across a continuum of care. The RN-CM will communicate with physicians and nurses regarding emergency and direct admissions based on bed availability, treatment plan and admission criteria; initiate and maintain communication throughout the day with Emergency Department, Operating Room, and specialty area. Attend daily care coordination rounds; strategize and recommend anticipated placement of patient to appropriate unit at appropriate time. The RN-CM will collect, analyze, evaluate and summarize data from referring hospitals, attending physicians, referring physicians and clinics regarding bed utilization; assess scheduled admissions, available beds and requested patient transfers on an on-going basis. The RN-CM will ensure compliance with standards related to pending discharges for current and following day in coordination with case managers. Collect, investigate and disseminate clinical data to other Patient Access Service personnel regarding diagnosis and treatment plans and insurance data for evaluation of admission criteria.
Utilization Review – Participates in the coordination of care and service of a patient population across a continuum of care. Perform and coordinate the initial assessments and ongoing reassessments of the patient's status, document patient case information within a database system, and perform chart review/audits monthly or as needed. The RN-CM ensures that health care services are administered with quality, cost efficiency, and within compliance. By continuously reviewing and auditing patient treatment files, the RN-CM will ensure that patients do not receive unnecessary procedures, ineffective treatment, or unnecessarily extensive hospital stays. The RN-CM reviews precertification requests for medical necessity. Initiate elective pre-certification and coordinate urgent/emergent admission authorization; coordinate out of network admission, lack of referral from primary care provider, no insurance, and other special admissions with attending physicians and others. Refer long-term diagnoses, length of stay more than five days and other high-risk diagnoses to case management to ensure that patients remain on proper clinical pathways.
Discharge Planning - Participates in the coordination of care and service of a patient population across a continuum of care. The RN-CM will participate in monthly case conferences by providing information pertinent to patient’s needs/goals as well as partner with the Program Director in development and review of the patient's individualized coordination of care plan. The RN-CM will ensure that the patient's medical needs are addressed; consult with the patient's physicians as needed, coordinating plans of treatment, and advocating for the patient when necessary. Identify and assist patient in accessing entitlements, resources, information, and referrals for psychosocial needs. Empower patients in decision making for care planning. Maintain accurate and timely patient information, which readily accessible for review and meet all requirements; assist in data collection for reporting/funding sources.
All organizational staff, including this position, are specifically required as a condition of continued employment to make advance preparations for their families and pets in the event of weather emergencies such as Hurricanes and flooding threats. Any staff member can be determined as essential staff required to report to the facility during these events. In many cases this means reporting and sleeping at the facility before, during and after a weather emergency. By signing this job description, the staff member accepts this responsibility of readiness to report to work during any designated emergency staffing situation. CMC staff members operate as one team meeting the healthcare needs of our communities, thus this position will on occasion complete other duties as assigned beyond those designated in this primary job description which may include “float” coverage at an alternate facility, department or assignment.
Light-Medium - While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to 2/3 of the time) required to stand, sit, and walk; frequently to use hands, fingers; and frequently to talk or hear. The employee must exert 15 to 20 pounds of force occasionally (activity or condition exists up to 1/3 of the time), and/or 5 to 10 pounds of force frequently, and/or greater than negligible up to 5 pounds of force constantly to move objects. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. Ability to hear to process instructions and safety code and alarms required. The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job and will be assessed by post offer Employee Health fit-for-duty review.