This position is responsible for the coordination of health care providers for the patients’ care to cooperatively prepare the patients for discharge. The employee is responsible for promoting effective team communications amongst the patient care providers with the goal of providing the optimal outcome for the patient and family for their continued care.
Reviews patient records for medical necessity of admission, appropriateness of the level of care being provided and potential need for extended length of stay.
Assigns LOS according to DRG guidelines and performs concurrent review within the assigned time frame, utilizing Interqual guidelines for concurrent review and discharge screening.
Discusses with the physicians the patient’s plan of care, diagnosis and assessments. Assists in the development of a plan of care that will ensure the patient’s health care needs are met in the appropriate level of care.
Follows the Utilization Review Plan’s process for physician advisor referrals in a timely manner, ensuring that patient care is provided in the appropriate level of care.
Reviews patient records and monitors for compliance with core measures, risk, quality and re-admission or other identified concerns.
Notifies the Infection Control Nurse of any public health issues (i.e., +TB, MRSA) or hospital acquired infection that may need to be reviewed for performance improvement as needed.
Coordinates care with nursing staff and other members of the healthcare team in the development of a plan of patient care.
Provides Medicaid patient information to KePRO within one working day to ensure authorization for in-patient care as required.
Responds to Medicaid denials by requesting reconsiderations as needed.
Reviews and updates Utilization Review Plan yearly for AHCA approval.
Assists as needed with patient transfers to another acute care facility, crisis unit and/or SNF/ECF.
Addresses end of life issues and provides information to Living Wills, Health Care Surrogate and Hospice care as appropriate.
Recognizes and reports signs and symptoms of child, adult and elderly abuse as guided in hospital policies and procedures.
Participates in the collection of data for Performance Improvement, Utilization Review and credentialing.
Performs a comprehensive pre-admission review within 24 hours of patient’s admission.
Collaborates with physicians and nursing staff to identify patients with discharge planning needs within 48 hours of admission.
Completes comprehensive assessments on high-risk patient discharge plans and needs.
Coordinates and communicates with nursing and medical staff in regards to social services or discharge planning activities on referred cases.
Provides information to nursing staff, medical staff and other staff on utilization, reimbursement and coverage issues for payer sources when the need is identified.
Maintains a working knowledge of Interqual, eqHealth and criteria for admission to the hospital and for the patient’s continued hospital stay.
Provides needed patient information to insurance and HMO providers as required by the payer sources to get authorization for continued care.
Performs on-going documentation of reviews and communications with insurance and agency providers.
Demonstrates working knowledge of reimbursement from the primary providers for the hospital as demonstrated by interaction with physicians and clinical departments in the coordination of efficient and effective patient care.
Monitors length of stay and communicates effectively potential discharge plans to the attending physicians and other clinical care providers.
Plans discharge procedures for patients preparing to leave the facility.
Represents the hospital in interagency networking to promote utilization of services throughout the Glades communities.
Interacts professionally with referral agencies and maintains a good working relationship with extended care facilities, home health agencies as well as other providers for continuing care after hospitalization to ensure the hospital is represented well and our patients are well served.
Maintains a working knowledge of referral resources to include skilled nursing facilities, home health agencies and durable medical equipment suppliers, which provide proven quality services.
Identifies and coordinates discharge planning assistance as needed for continuing care needs following discharge of the patient from the hospital to include ECF, SNF and home health care.
Ensures the coordination of community resources and equipment needs post discharge.
Completes medical chart reviews for charges audits and HMO reviews as assigned.
Recognizes and reports signs and symptoms of child, adult and elderly abuse, as guided in hospital policy and procedure.
Assists in the referral of patients to community resources such as CARP, CAP and Mental Health as needed.
Coordinates with the medical staff and nursing staff to ensure effective utilization of resources for the patient’s care.
Participates in the collection of data for credentialing as required.
Participates in the surveillance and reporting for Performance Improvement, Infection Control and Risk Management.
Participates on assigned hospital committees such as Medical Record Review Audit, Case Management and others as the need is identified.
Emergency duty may be required of the incumbent that includes working in special needs or Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.
Associates degree required.
Four (4) years experience required for this position.
Case Manager Certification preferred.