Case Management Nurse
Available Opportunity at Kansas Heart Hospital
Job Function: Performs a variety of duties and applies utilization and case management techniques to determine the most efficient use of resources to support the provision of appropriate, cost effective and quality health care. Works in a team model to address patient discharge needs. The CM nurse provides leadership in the integration of utilization and case management principles throughout the hospital.
- Current and valid license to practice as a Registered Nurse (BSN Required, Masters preferred) in the state of Kansas.
- Case Manager Certification.
- Three or more years of Case Management experience.
- Three or more years strong clinical experience in clinical practice area to which assigned.
- BLS certification.
- Excellent interpersonal communication and negotiation skills.
- Demonstrated leadership skills.
- Strong analytical, data management and PC skills (Microsoft Word, Excel, InterQual preferred).
- Current working knowledge of discharge planning, utilization management, case management, performance improvement and managed care reimbursement.
- 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, payors, and patients and their families.
Job Duties and Responsibilities:
- Performs initial reviews for medical necessity and appropriateness of setting for the assigned case load.
- Conducts concurrent reviews to ensure medical necessity for continued hospitalization and initiates problem-solving techniques as needed to prevent over and/or under-utilization.
- Liaisons between third party payors and the treatment team regarding the identified treatment plan in accordance with contractual guidelines or hospital policy.
- Maintain daily contact with physician and hospital staff regarding plan of care. Ensures the process of updating primary care physicians on patient progress.
- Conducts and documents initial patient assessment to include social, family and disposition status; determines tentative initial discharge plans in conjunction with patient/family goals. Maintains accurate up-to-date documentation in the medical records of patient and family contacts and other services performed on behalf of patient and family.
- Conducts and coordinates timely discharge planning. Assist in coordination of discharge plan by assisting with arrangements for family education, equipment, outpatient therapy and other services as appropriate for patient’s discharge level of care. Assists with discharge planning process: identification, assessment, collaboration, planning, communication, referrals, and follow-up by assisting with education, medical equipment, Home Health, outpatient therapy and other services as appropriate for patients discharge level of care. As required, updates external case manager and or pay or source regarding progress, plan and patient’s future needs.
- Identifies patients who are a high risk for discharge or other significant problems and refers to social worker.
- On a concurrent basis, assists in identifying quality and clinical risk issues and reports to appropriate individuals/areas for further review and monitoring.
- Assists with appeals process and data entry and attends team or medical staff meetings as requested.
- Assists with the collection and analysis of utilization patterns and denied cases.
- Works closely with the Coders, Clinical Documentation Specialist and Physicians. Provides the physicians with the clinical expertise and acts as a liaison with utilization issues relative to documentation and appropriate status designation.
- Maintain established policies and procedures, objectives, quality assessment and safety standards.
- Develops and initiates educational programs regarding utilization management principles.
KHH considers applicants for all positions without regard to race, religion, color, sex (including pregnancy and gender identity), national origin, age, disability, family medical history, or genetic information.
Employment is subject to satisfactory completion of a pre-employment drug screening program.