Job Details
Job Location: BHH Valley Street - Bristol, CT
Position Type: Full Time
Salary Range: Undisclosed
Job Shift: 1st Shift (Days)
Job Summary
At Bristol Health, we begin each day caring today for your tomorrow. We have been an integral part of our community for the past 100 years. We are dedicated to providing the best possible care and service to our patients, residents and families. We are committed to provide compassionate, quality care at all times and to uphold our values of Communication, Accountability, Respect and Empathy (C.A.R.E.). We are Magnet ® and received the 2020 Press Ganey Leading Innovator award for our rapid adoption and implementation of healthcare solutions during the COVID-19 pandemic. Use your expertise, compassion, and kindness to transform the patient experience. Make a difference. Make Bristol Health your choice.
Under the general supervision of the Manager/Director, nurses in the Case Manager role provide clinically-based case management to support the delivery of effective and efficient patient care. Paces cases from physiological and economic perspectives. Has overall accountability for the utilization management and transition management for patients within the assigned caseload. Partners with Social Workers and collaborates with other health care team members to identify appropriate utilization of resources and to ensure reimbursement. Utilizes criteria to confirm medical necessity for admission and continued stay. With the patient, family and health care team, creates a discharge plan appropriate to the patient’s needs and resources.
Essential Job Functions and Responsibilities:
- Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents information in the current electronic system (such as MIDAS).
- Validates admission and continuing stay criteria with third party payers (including onsite and telephonic Case Managers) as well as Primary Care and Attending Physicians. Recommends alternative care sites where appropriate.
- Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial. Intervenes to prevent the denial where possible.
- Supports the effective prevention and management of denials, including drafting appeal letters and/or providing information as part of the appeal process.
- Assesses the patient and family for continuing care needs to develop, implement and evaluate an effective discharge plan in collaboration with the multidisciplinary team. Uses knowledge of usual length of stay to initiate a plan for discharge.
- Collaborates and communicates with patients/families related to reimbursement issues and to create a discharge plan. Supports the process of patient choice in establishing a discharge plan.
- Uses clinical knowledge and knowledge of anticipate response to treatment to assess patient progression towards anticipated outcomes. Communicates and coordinates with the patient/family and health care team to Intervene when progression is stalled or diverted. Addresses actual/potential barriers to discharge.
- Completes the interventions necessary for discharges to home with self-care, home with services and short term skilled nursing facility placement. Assembles necessary referrals, discharge summaries and pertinent information for placement prior to the day of discharge.
- Actively contributes to, participates in, and follows through on interventions identified in care coordination and complex patient rounds.
- Identifies high risk patients and creates a collaborative plan to address their unique needs.
Qualifications
Educational / Minimum Requirements:
Minimum of 5 years of broad clinical experience, predominately in medical/surgical nursing.
Case Management, discharge planning and utilization review experience preferred.
Licensed as a Registered Nurse in the state (or eligible for licensure)
BSN preferred or actively working towards BSN.
State/Federal Mandated Licensure or Certification Requirements:
Current state of Connecticut RN Licensure
Bristol Hospital Mandated Educational Requirements:
General orientation at time of hire. Fire/Safety/Infection control annually. CPR, Code Blue & Accucheck annually, IV Medication & Blood Administration at time of orientation. Other programs as mandated by Hospital.
Physical Requirements:
Considerable walking, standing, sitting, stooping and bending. Considerable paperwork and video display terminal work requiring extensive eye usage.
Work Environment:
Normal nursing unit environment, including patient furnishings and equipment.
Special Requirements:
Strong interpersonal, communication, and negotiation skills.
Ability to form positive, collaborative relationships with hospital staff, patients and families.
Ability to effectively negotiate with internal and external providers of patient care services.
Analytical abilities to assist in obtaining solutions to problems.
Able to work independently and prioritize work.
Able to manage multiple priorities.
Basic knowledge of computers and clinical applications.
Ability to problem solve in a proactive, creative manner using sound judgment based on factual information and clinical knowledge.
Communicate in a clear, concise, and logical manner in oral and written presentations.
Disclaimer
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.
