Overview

Under the general supervision of the case management Director acts as a patient advocate/case manager to hospital clients. An autonomous role that coordinates, negotiates, procures services and resources for, and manages the care of complex patients to facilitate achievement of quality and cost efficient patient outcomes. Looks for opportunities to reduce cost while ensuring the highest quality of care is maintained. Applies review criteria to determine medical necessity for admission and continued stay. Provides clinically based case management, discharge planning, and care coordination to facilitate the delivery of cost-effective quality healthcare and assists in the identification of appropriate utilization of resources across the continuum of care.  Works collaboratively with interdisciplinary staff internal and external to the organization. Participates in quality improvement and evaluation processes related to the management of patient care.

Responsibilities:

Does the initial screening of all elective inpatient admissions related to:

• Level of care
• Appropriateness of admission (IS-SI)
• Discharge needs
• Third party contractual arrangements
• Appropriate resource utilization
• Coordinates the pre-admission screening and education of the identified patient populations
• Coordinates out-of-area transfers
• Documents patients admitted directly through Pre-Admissions in the lap top system and forwards the information on to the Case Managers as appropriate with discharge planning concerns and the initial discharge-planning screen.

A) Develops educational programs (pre/post op surgeries), high risk screening tools, Care-Maps for the Pre-Admit phase of identified populations and proactive discharge planning.

B) Coordinates OOA/OON Managed Care admissions, as well as meeting criteria and the Level of Care, which is appropriate according to lnterqual and Milliman & Robertson Guidelines.

C) Serves as a resource in selecting and assigning the admission types (i.e. In Patients, 23:59, SOS, etc.)

D) Interacts with the admitting MD as appropriate involving the Physician Advisor as needed for inappropriate admits/transfers/level of care.

E) Oversees that Pre-Admit T AR's are obtained and the patients payer sources have the appropriate network among the patients health care team (i.e. Case Mgmt., Business Office, Physicians, Social Services, Nurse Manager, etc.)

F) Is a clinical resource to admitting department and provides ongoing education on the effective resources of the Pre Admission Case Manager and Quality/Case Management Department to physicians, physician office staff, nursing.

G) Maintains identified tracking and data statistics as requested by Commitment to Quality role in Case Management.

Is aware of and follows all hospital and department process policies and procedures.

A) Is knowledgeable of Improvement performance/process improvement (P. I.) methodology.

B) Can verbalize knowledge of hospital-wide performance/process improvement activity.

C) Offers suggestions for departmental and/or hospital-wide performance/process improvement.

D) Knowledge of and participation in the performance/process improvement is a condition of employment.

E) As observed by representatives of management, all interactions are conducted in a professional manner.

F) Verbal and written feedback from patients, family members/significant others, medical staff, visitors and co-workers indicates behavior conducive to positive guest relations.

G) Consistently exhibits appropriate phone protocol (e.g., answers phones promptly, is courteous, helpful and identifies self and department).

H) Consistently contributes to the team effort (e.g., assists co-workers when need is observed or upon request, offers constructive suggestions rather than complaints).

I) Consistently displays cheerful and positive attitude.

J) Maintains high productivity and performs efficiently regardless of whether the work volume is high or low.

K) Appropriately prioritizes work activities.

L) Responds to difficult situations with self-control and a positive attitude.

M) Makes decisions independently and knows when to ask for assistance.

N) Exercises good judgement and arrives at sound decisions.

O) Maintains high productivity and performs efficiently regardless of whether the work volume is high or low.

P) Appropriately prioritizes work activities.

Q) Responds to difficult situations with self-control and a positive attitude.

U) Makes decisions independently and knows when to ask for assistance.

R) Exercises good judgement and arrives at sound decisions.

S) Employee reports to work each regularly scheduled workday.

T) Is ready for work at precise starting time and continues working until scheduled departure time.

U) Readily accepts work assignments in a positive manner.

V) Performs work that is accurate, neat and consistent.

W) Documentation is legible.

X) Keeps / work area neat and maintains equipment in accordance with health and safety codes.

Y) Reports safety issues and equipment failures appropriately.

Z) Projects a professional image, follows the hospital dress code policy and/or department requirements.

AA) Wears hospital ID badge at all times on duty.

BB) Sensitive information including, but not limited to, patient records, charts, hospital documents and employee information is kept confidential without exception.

CC) Completes annual requirements (PPD, requirements, Annual Update, Ethics Training, Licensure and/or Professional Certification} on time.

DD)  Communicates in a clear, courteous and professional manner.

EE) Completes annual safety updates within established time frames.  b) Completes general and departmental orientation within established time frames.  c) Attends 100% of mandatory in-service programs.  d) Maintains licensure/certification as appropriate.  e) Attends 75% of staff meetings or reads and initials minutes.  f) Keeps up with reading memos without reminders.  g) Does continuing education programs on time and with good test scores.

FF) Consistently strives to understand, anticipate and meet the needs, expectations and satisfaction levels of patients and other “customers”.  b) Errors, inefficiencies and inaccuracies are brought to management‘s attention with suggestions for improvement.  c) Develops innovative solutions to departmental problems.  d) Identifies and implements methods of controlling coast or generating revenue while providing maximum value to both the patient/customer and the hospital.  e) Maximizes efficiency in all departmental operations.  f) Measures progress against quality goals.  g) Actively promotes our Attitude is Everything, Core Measure, No Pass Zone, Avatar and Front Stage/Back-Stage goals.

A) Coordinates and supervises data and reporting needs and provides timely discharge planning.

B) Frequent contact with other organization units, outside facilities staff to obtain, verify and/or provide information for the discharge follow up.

C) Answers inquires and education the patients/family, physicians and hospital staff on discharge.

D) May coordinate and supervise Air & Ground transportation.

E) Coordinates and supervise cases and referral information {SNF, Home health and DME)

F) Maintain the consistency and integrity of Case Management/Social Services bed track data.

Qualifications:

• Minimum Education:  Preferred Bachelors of Science/Nursing or Bachelors of Health Care Administration. 
• Minimum Experience:  Minimum of 5 years’ experience in the acute care setting. Working knowledge of lnterQual IS-SI, Milliman and Robertson Managed Care Guidelines, Erickson Life Skills (Age Competencies}, Medicare Part A and Part B, Medi-Cal, NCQA, HEDIS and other criteria as identified by the Quality/Case Management Department. Working knowledge of Care-M.A.P. development and implementation. Minimum of 1 year of discharge planning experience. Working knowledge of managed care and capitation. 
• Required Certification/Registration: Current, valid California L VN or RN license.