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RN Case Manager - Holmes Regional Medical Center, Full Time - Case Management

Company: Health First Holmes Regional Medical Center
Location: Melbourne
Posted on: September 17, 2022

Job Description:

RN Case Manager - Holmes Regional Medical Center, Full TimePosition Summary:

To be fully engaged in providing Quality/No Harm, Customer Service and Stewardship by coordinating the care and services for a defined patient population to promote the achievement of optimal clinical and resource outcomes. The RN Case Manager utilizes advanced clinical skills to facilitate the provision of care including the appropriate length of stay, patient status management, resource utilization and discharge planning for all hospital admissions. The RN Case Manager utilizes advanced clinical skills to facilitate the provision of care which includes the assessment, planning, intervention and evaluation of patient care in accordance with our Conditions of Participation, State of Florida regulations, JCAHO accreditation standards and hospital goals.The RN Case Manager uses their analytic abilities to evaluate current systems and variances, to help identify and implement opportunities for improvement. RN Case Managers use independent clinical judgment and works collaboratively with the interdisciplinary team to promote quality of care through collaboration with all team members, patients, families and significant support personnel.

Primary Accountabilities:

Quality/No Harm:

* The RN Case Manager plans effectively to meet patient needs during their hospital stay regarding processing them through the system and managing the length of stay, promoting efficient utilization of resources, and plans for a safe discharge continually evaluating and updating patient status. Specific functions within this role include:
* Facilitation of patient's transitional plan in collaboration with the physician, nursing and interdisciplinary team.
* Facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove and escalate barriers to timely and efficient care delivery and resource utilization.
* Application of process improvement methodologies in evaluating outcomes of care.
* Identifies at-risk populations using approved screening tool and follows established referral processes for patients.
* Promotes professional practice through collegial support and interactions.
* Practices autonomously, consistent with evidence-based standards.
* Pursues personal and professional growth and development. Serves as a professional role model and mentor.
* Serves as an expert resource to all hospital staff regarding areas of case management compliance. Example; Medicare IM letter, 3008, 1823 PASSR, and DCF mandatory legal reporting.
* Represent Case Management Department at Quality No Harm meetings when requested, and actively participates in performance improvement opportunities.
* Works collaboratively with Care Transitions team to identify high risk patients and assure safe transition to the next level of care to prevent readmissions.
* Assess the clinical situation and identifies any areas impeding patient progression towards desired goals within timeframe assigned.
* Utilizes both medical record review and physical assessment to comprehensively assess patient.
* Interacts with support departments when avoidable delays are recognized and documents denied days and delays in electronic system...
* Identifies complex cases with multiple practitioners and facilitates decision-making and communication to ensure resolution of care issues.
* Identifies clinical or system/process breakdowns and improvement opportunities.
* Proposes alternative treatment options in a timely manner to achieve desired outcomes.


* Works with the Physician Advisor, Utilization Department, Hospitalist, ED physicians and other physicians to ensure appropriateness of care, cost-effectiveness and best patient outcomes.
* Identifies problems with care delivery system that impact on length of stay, quality and continuity of care and participates in process improvement.
* Addresses/resolves system problems impeding diagnostic or treatment progress.
* Monitors observation hours and facilitates assignment of timely patient status based on medical necessity documentation.
* Proactively identifies resolves or escalates delays and obstacles to discharge.
* Accountable to appropriate documentation of avoidable delays data.
* Accountable to continuing education and understanding of Interqual and MCG.
* Applies approved clinical criteria by use of Interqual or MCG to monitor appropriateness of admissions and continued stays, and documents findings based on department standards.
* Monitors length of stay and ancillary resource use on an ongoing basis.
* Takes actions to achieve continuous improvement in both areas.
* Refers cases and issues to Physician Advisor in compliance with department procedures and follows up as indicated.
* Maintain current knowledge of Utilization Management and forms associated with CMS guidelines.
* Discusses payer criteria and issues on a case-by-case basis with Physician Advisor, clinical staff and care management leadership and follows up to resolve problems with payers as needed.
* Identifies reimbursement factors influencing the choice of post-hospital providers and obtains authorizations as required, either directly or in collaboration with the case manager. Educates the patient and family about reimbursement, including out of pocket cost to the patient.
* Demonstrates understanding of level of care criteria and reimbursement factors for home care, rehabilitation, outpatient treatment, residential treatment and long term care in development of discharge plans. Seeks alternatives to facilitate discharge planning, and creates relationships with all supportive organization to help in the discharge process.

Customer Experience:

* Works with the physician advisor, physicians, nursing, ambulatory programs, outpatient programs, interdisciplinary team and health plan for defined patient populations to develop clinical appropriate transitional pathways, continuum care management for patient care and patient satisfaction.
* Initiates care transition at time of admission, develops and revises individualized discharge plans as indicated by assessment and patient response to treatment.
* Evaluates overall plan daily for effectiveness and involves the patient and family in the formulation of goals.
* Works collaboratively and maintains active communication with physicians, nursing, physician advisor, and other members of the interdisciplinary care team to effect timely, appropriate patient resource management, and patient transition.
* Seeks consultation from appropriate disciplines/ancillary departments as required to expedite care and facilitate patient transition.
* Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
* Committed to maintain the professional standards of Nursing.
* Collaborates with the physician and all members of the interdisciplinary team to facilitate care, monitors the patient's progress, intervening as necessary and appropriate to ensure that transition plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis:
* Completion of patient assessment/reassessment and transition plan;
* Modification of transition plan, as necessary, to meet the ongoing needs of the patient;
* Communication to third party payers and other relevant information to the care team;
* Timely assignment of appropriate patient status;
* Provides education for members of care team regarding appropriate utilization of services and levels of care indicated by a clinical situation.
* Completion of all required documentation in electronic medical record.
* Collaborates with other disciplines in patient evaluation and treatment and initiates referrals appropriately.
* Identifies at-risk populations using approved screening tool and follows established referral processes for patients.
* Collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting.
* Initiates appropriate referrals to ethics committee, clinical social worker, risk management or legal services as appropriate.
* Demonstrates professional accountability through supporting patient's rights, informed consent and advanced directives.

REV 3/20/19

Qualifications Required:

* Current valid license to practice as a Registered Nurse in the State of Florida
* Bachelor's Degree or college degree in related field preferred.
* Case Manager Certification (CCM or ACM) preferred.
* Three (3) or more year's clinical experience required;
* Case Management experience preferred.
* Must hold current AHA BLS Healthcare provider completion card
* Excellent interpersonal communication and negotiation skills.
* Demonstrated leadership skills.
* Strong analytical, data management and computer skills.
* Current working knowledge of care transitions, utilization management, case management, performance improvement and managed care reimbursement preferred.
* Understanding of pre-acute and post-acute venues of care and post-acute community resources.
* Strong organizational and time management skills, as evidenced by capacity to prioritize multiple tasks and role components.
* Ability to work independently and exercise sound judgment in interactions with physicians, payers, and patients and their families.
* Performs duties in a manner to promote quality patient care and customer service/satisfaction, while promoting safety, cost efficiency, and a commitment to the process improvement process.
* Excellent writing and presentation skills.

Physical Demands:

* Able to stand, walk, sit and travel large distances repeatedly in a timely manner.
* Able to lift up to twenty (20) pounds unassisted, up to five (5) times a day.
* Ability to hear and understand patient, family and medical staff correctly.
* Ability to meet deadlines.
* Must be a self-starter.
* Must be able to communicate with patients, families and staff.
* Must be able to tolerate a minimum of 3-5 hours of computer time a day.

Mental Demands:

* RN Case Manager must demonstrate critical thinking skills in all aspects of work performed, and demonstrates an ability to be flexible, organized and functional under stressful situations.

Keywords: Health First Holmes Regional Medical Center, Melbourne , RN Case Manager - Holmes Regional Medical Center, Full Time - Case Management, Executive , Melbourne, Florida

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