The RN Case Manager is responsible to facilitate care along a continuum through effective resource coordination to help patients achieve optimal health, access to care and appropriate utilization of resources, balanced with the patientï¿½s resources and right to self-determination. The individual in this position has overall responsibility for ensuring that care is provided at the appropriate level of care based on medical necessity and to assess the patient for transition needs to promote timely throughput, safe discharge and prevent avoidable readmissions. This position integrates national standards for case management scope of services including:
ï¿½Utilization Management supporting medical necessity and denial prevention
ï¿½Transition Management promoting appropriate length of stay, readmission prevention and patient satisfaction
ï¿½Care Coordination by demonstrating throughput efficiency while assuring care is the right sequence and at appropriate level of care
ï¿½Compliance with state and federal regulatory requirements, TJC accreditation standards and Tenet policy
ï¿½Education provided to physicians, patients, families and caregivers
The individualï¿½s responsibilities include the following activities: a) accurate medical necessity screening and submission for Physician Advisor review, b) care coordination, c) transition planning assessment and reassessment, d) implementation or oversight of implementation of the transition plan, e) leading and facilitating multi-disciplinary patient care conferences, f) managing concurrent disputes, g) making appropriate referrals to other departments, h ) identifying and referring complex patients to Social Work Services, i) communicating with patients and families about the plan of care, j) collaborating with physicians, office staff and ancillary departments, k) leading and facilitating Complex Case Review, l) assuring patient education is completed to support post-acute needs , m) timely complete and concise documentation in Case Management system, n ) maintenance of accurate patient demographic and insurance information, o) identification and documentation of potentially avoidable days, p) identification and reporting over and underutilization, q) and other duties as assigned.
POSITION SPECIFIC RESPONSIBILITIES:
?Balances clinical and financial requirements and resources in advocating for patient needs with judicious resource management
?Assures the patient is in the appropriate status and level of care based on Medical Necessity process and submits case for Secondary Physician review per Tenet policy
?Ensures timely communication of clinical data to payers to support admission, level of care, length of stay and authorization for post-acute services
ï¿½Advocates for the patient and hospital with payers to secure appropriate payment for services rendered
ï¿½Promotes prudent utilization of all resources (fiscal, human, environmental, equipment and services) by evaluating resources available to the patient and balancing cost and quality to assure optimal clinical and financial outcomes
ï¿½Identifies and documents Avoidable Days using the data to address opportunities for improvement
ï¿½Prevents denials and disputes by communicating with payers and documenting relevant information
ï¿½Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued stay, discharge and post- acute care) compared to evidence-based practice, internal and external requirements.
(30% daily, essential).
ï¿½Completes comprehensive assessment within 24 hours of patient admission to identify and document the anticipated transition plan for patients
ï¿½Integrates key elements of patient assessment, patient choice and available resources to develop and implement a successful transition plan
ï¿½Identifies patients at risk for readmission and applies appropriate intervention including risk assessment and referral to Social Work services and/or Complex Case Review
ï¿½May delegate the implementation of the transition plan to LVN/LPN or Assistant staff. And follows up to ensure the transition plan is completed timely and accurately
ï¿½Ensures all elements of the transition plan are implemented and communicated to the healthcare team, patient/family and post-acute providers
ï¿½Provides information to patients to make informed choices when community services per Tenet policy
ï¿½Completes Final Discharge Disposition Form Assessment for Medicare patients per Tenet policy
ï¿½Identifies and reports variances in appropriateness of medical care provided, over/under utilization of resources compared to evidence-based practice and external requirements. This priority includes documentation in the Tenet Case Management system to communicating information through clear, complete and concise documentation
(30% daily, essential)
ï¿½Screens patients for factors that may affect the progression of care and intervenes as needed to promote timely and appropriate throughput
ï¿½Conducts assessments and stratifies patients at risk for readmission or in need of Case Management services
ï¿½Ensures the plan of care is clinically appropriate, consistent with patient choice and available resources
ï¿½Ensures consults, testing and procedures are sequenced to support the patients clinical needs with timely and efficient care delivery
ï¿½Ensures patient needs are communicated and that the healthcare team is mutually accountable to achieve the patient plan of care
ï¿½Effectively collaborates with physicians, nurses, ancillary staff, payors, patients and families to achieve optimum clinical outcomes
(15% daily, essential)
ï¿½Ensures and provides education to patients, physicians and the healthcare team relevant to the
oEffective progression of care,
oAppropriate level of care, and
oSafe and timely patient transition
ï¿½Provides patient and healthcare team education regarding resources and benefits available to the patient along with the economic impact of care options
ï¿½Ensures that education has been provided to the patient/family/caregiver by the healthcare team prior to discharge
(15% daily, essential)
ï¿½Ensures compliance with federal, state, and local regulations and accreditation requirements impacting case management scope of services
ï¿½Adheres to department structure and staffing, policies and procedures to comply with the CMS Conditions of Participation and Tenet policies
ï¿½Operates within the LVN/LPN scope of practice as defined by state licensing regulations
ï¿½Remains current with Tenet Case Management practices
(10% daily, essential)
1.Graduate from an accredited school of nursing. Bachelorï¿½s degree in Nursing or other health-related field, or equivalent combination of education and/or related experience.
2.Two years of acute hospital patient care experience. Acute hospital case management experience preferred.
3.License to practice as a Registered Nurse in the State of Michigan.
4.Accredited Case Manager (ACM) preferred.
5.Must complete Tenetï¿½s InterQual education course within 30 days of hire (and at least annually thereafter) and pass with a score of 85 or better. Must complete and demonstrate competency in using the Tenet Case Management documentation system within 30 days of hire. Attendance at hospital and department orientation is required. Department orientation includes review and instruction regarding Tenet Case Management and Compliance policies, InterQualï¿½, Transition Management, Utilization Management, and other topics specific to case management.
1.Analytical ability, critical thinking, problem solving skills and comprehensive knowledge base to identify opportunities for improvement and problem resolution, evaluate patient status and health care procedures/techniques, and monitor quality of patient care.
2.Knowledge of care delivery capabilities along the continuum of care.
3.Interpersonal skills to work productively with all levels of hospital personnel.
4.Resourcefulness to identify prompt and sustainable solutions to barriers in care delivery.
5.Verbal and written communication skills to communicate effectively with diverse populations including physicians, colleagues, patients and families.
6.Teaching abilities to conduct educational programs for staff.
7.Flexibility with schedule, including off-shifts, weekends and holidays in order to meet the needs of patients, families or staff.
8.Organizational skills and ability to lead and coordinate activities of a diverse group of people in a fast paced environment, and direct others toward objectives that contribute to the success of the department.
9.Ability to cope with stressful situations, manage multiple and sometimes conflicting priorities simultaneously.
10.Computer literacy to utilize case management systems.
Job: Case Management/Home Health
Primary Location: Commerce Township, Michigan
Facility: DMC Huron Valley-Sinai Hospital
Job Type: Full-time
Shift Type: Days
Employment practices will not be influenced or affected by an applicantâ��s or employeeâ��s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
Internal Number: 1905028330
About DMC Huron Valley-Sinai Hospital
“Tenet Healthcare Corporation is a diversified healthcare services company with 115,000 employees united around a common mission: to help people live happier, healthier lives. Through its subsidiaries, partnerships and joint ventures, including United Surgical Partners International, the Company operates general acute care and specialty hospitals, ambulatory surgery centers, urgent care centers and other outpatient facilities. Tenet's Conifer Health Solutions subsidiary provides technology-enabled performance improvement and health management solutions to hospitals, health systems, integrated delivery networks, physician groups, self-insured organizations and health plans.