Utilizing a collaborative process, the care manager will assess, plan, implement, monitor, and evaluate the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes. The care manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the patient and the reimbursement source.
POSITION SUMMARY:
Utilizing a collaborative process, the care manager will assess, plan, implement, monitor, and evaluate the options and services required to meet an individual’s health needs, using communication and available resources to promote quality, cost-effective outcomes. The care manager helps identify appropriate providers and facilities throughout the continuum of services while ensuring that available resources are being used in a timely and cost-effective manner in order to obtain optimum value for both the patient and the reimbursement source.
The care manager is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include:
Assessment - The care manager will collect in-depth information about a person’s situation and functioning to identify individual needs in order to develop a comprehensive care management plan that will address those needs.
Planning – The care manager will determine specific objectives, goals, and actions as identified through the assessment process. The plan should be action oriented and time specific.
Implementation – The care manager will execute specific intervention that will lead to accomplishing the goals established in the care management plan.
Coordination – The care manager will organize, integrate, and modify the resources necessary to accomplish the goals established in the care management plan.
Monitoring – The care manager will gather sufficient information from all relevant sources in order to determine the effectiveness of the care management plan.
Evaluation – At appropriate and repeated intervals, the care manager will determine the plan’s effectiveness in reaching desired outcomes and goals. This process might lead to a modification or change in the care management plan in its entirety or in any of its component parts.
Position: RN Care Manager
Department: 3 Surgical Step Down
Schedule: 40 Hours (Days / Rotating Weekends) 10 Hour Shifts
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Conduct a thorough and objective evaluation of the client’s current status including physical, psychosocial, environmental, financial, and health status expectation. As a client advocate, seek authorization for care management from the recipient of services (designee). Coordinates/facilitates patient care progression throughout the continuum.
- Works collaboratively and maintains active communication with physicians, nursing, and other members of the multidisciplinary care team to effect timely, appropriate patient management.
- Ensures appropriate clinical pathway assignment by staff nurses
- Addresses/resolves system problems impeding diagnostic or treatment progress.
- Proactively identifies and resolves delays and obstacles to discharge.
- Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge.
- Utilizes advanced conflict resolution skills as necessary to ensure timely resolution of issues.
- Collaborates with the physician and all members of the multidisciplinary team to facilitate care for designated caseload; monitors the patient’s progress, intervening as necessary and appropriate to ensure that the plan of care and services provided are patient focused, high quality, efficient, and cost effective; facilitates the following on a timely basis:
Completion and reporting of diagnostic testing
Completion of treatment plan and discharge plan
Modification of plan of care, as necessary, to meet the ongoing needs of the patient
Communication to 3rd party payers and other relevant information to the care team
Assignment of appropriate levels of care
Completion of all required documentation in TQ screens and patient records
Maintain communication and collaborates with medical staff, nursing staff, and ancillary staff to eliminate barriers to efficient delivery of care in the appropriate setting. Completes utilization management and quality screening for assigned patients.
- Applies approved utilization acuity criteria to monitor appropriateness of admissions and continued stays and documents findings based on department standards.
- Identifies at-risk populations using approved screening tool and follows established reporting procedures
- Monitors length of stay (LOS) and ancillary resource use on an ongoing basis. Takes actions to achieve continuous improvement in both areas.
- Assess resource utilization and cost management; the diagnosis, past and present treatment; prognosis, goals (short-and long-term).
- Refers cases and issues to physician advisor in compliance with department procedures and follows up as indicated.
- Communicates with resource center to facilitate covered day reimbursement certification for assigned patients. Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payers as needed.
- Uses quality screens to identify potential issues and forwards information to the quality review department.
- Identify opportunities for intervention
- Set goals and time frames for goals appropriate to the individual.
- Arrange, negotiate fees for, and monitor appropriate cases and services for the client.
Ensures that all elements critical to the plan of care and clinical path have been communicated to the patient/family and members of the health care team and are documented as necessary to ensure continuity of care. Manages all aspects of discharge planning for assigned patients.
- Meets directly with patient/family to assess needs and develop an individualized continuing care plan in collaboration with the physician.
- Collaborates and communicates with multidisciplinary team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation.
- Ensures/maintains plan consensus from patient/family, physician, and payer.
- Refers appropriate cases for social work intervention based on department criteria.
- Collaborates/communicates with external care managers.
- Initiates and facilitates referrals through the resource center for home health care, hospice, and medical equipment and supplies.
- Documents relevant discharge planning information in the medical record according to department standards.
- Facilitates transfer to other facilities for care management population.
Actively participates in clinical performance improvement activities.
- Assists in the collection and reporting of financial indicators including case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials, and appeals.
- Uses data to drive decisions and plan/implement performance improvement strategies related to care management for assigned patients, including fiscal, clinical, and patient satisfaction data.
- Establish measurable goals that promote evaluation of the cost and quality outcomes of the care provider.
- Collects, analyzes, and addresses variances from the plan of care/care path with physician and/or other members of the health care team. Uses concurrent variance data to drive practice changes and positively impact outcomes.
- Collects delay and other data for specific performance and/or outcome indicators as determined by the director of outcomes management.
- Documents key clinical path variances and outcomes that relate to areas of direct responsibility (e.g., discharge planning). Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently.
- Participates in the development, implementation, evaluation, and revision of clinical pathways and other care management tools as a member of the clinical resource/team. Assists in the compilation of physician profile data regarding LOS, resource utilization, denied days, costs, case mix index, patient satisfaction, and quality indicators (e.g., readmission rates, unplanned return to OR, etc.).
- Report quantifiable impact, quality of care and/or quality of life improvement as measured against the care management goals.
Conforms to hospital standards of performance and conduct, including those pertaining to patient rights, so that the best possible customer service and patient care may be provided. Utilizes hospital's Values as the basis for decision-making and to facilitate the division's hospital mission. Follows established hospital infection control and safety procedures.
OTHER DUTIES:
Provide coverage for Admitting, Emergency Department, and/or other unit-based Care Managers, as directed. Perform other duties as needed.
The above statements are intended to describe the nature and level of work performed. They are not intended to be construed as an exhaustive list of all duties required of personnel so classified. Employees may be assigned to other duties as required.
JOB REQUIREMENTS
EDUCATION:
- Nursing degree: Diploma, ASN or BSN (preferred), Ability to obtain BSN within 4 years
CERTIFICATES, LICENSES, REGISTRATIONS REQUIRED:
- Licensure to practice as a registered nurse in the state of Massachusetts, required.
- CCM or related certification preferred or attained within 24 months from date of hire.
EXPERIENCE:
- A minimum of 3-5 years’ clinical experience.
KNOWLEDGE AND SKILLS:
- Coordination and Service Delivery – The care manager will understand confidentiality and the legal and ethical issues pertaining to it; understand medical terminology, how to obtain an accurate history; establish treatment goals; establish working relationships with referral sources; develop treatment plans.
- Physical and Psychological Factors – The care manager will understand methods for assessing an individual’s level of physical/mental impairment; understand the physical and psychological characteristics of illness; be able to assist individuals with the development of short- and long-term health goals.
- Benefit Systems and Cost Benefit Analysis – The care manager will understand the requirements for prior approval by payer; be able to evaluate the quality of necessary medical services; be able to acquire and analyze the cost of care; understand the various health care delivery systems and payer plan contracts; be able to demonstrate cost savings.
- Case Management Concepts – The care manager will understand case management philosophy and principles; apply problem solving techniques to the care management process; document care management services; understand liability issues for care management activities.
- Community Resources – The care manager will understand how to access and evaluate the available resources to meet a client’s needs; will be able to develop new resources.
- Excellent interpersonal, verbal, and written communication and negotiation skills Strong analytical, data management, and PC skills.
- Current working knowledge of discharge planning, utilization management, case management, performance improvement, and managed care reimbursement.
- Understanding of preacute and postacute venues of care and postacute community resources.
- Strong organizational and time management skills, as evidenced by a 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.
Equal Opportunity Employer/Disabled/Veterans
