Overview
To provide a comprehensive approach to case management inclusive of all aspects of the patient's stay including, but not limited to the following key functions: discharge planning and execution of the discharge plan; ensuring proper utilization management requirements of payers are met; identification and capture of key clinical conditions by physician documentation; and institution of actions to support quality and safety initiatives.
Ideal candidate Previous case management experience preferred, 2 years minimum acute care/Rehab nursing experience, previous charge nurse experience would be a plus as well
Qualifications
Certifications: Licensed Registered Professional Nurse (RN) - Illinois Department of Financial and Professional Regulation (IDFPR); Certified Case Manager within 2 years - Commission for Case Manager Certification (CCMC), Education: College Diploma: Nursing, Work Experience: Acute care
Responsibilities
Performs intensity of service/severity of illness/disease specific reviews throughout patient stay.
- Applies and documents medical necessity reviews on admission and continued stay
- Notifies appropriate parties (physicians, nursing staff, patient, families, and other members of the care team as appropriate) when patients not meeting criteria and initiates measures to mitigate risk (discharge or better documentation to support clinical situation)
- Demonstrates accurate documentation of medical necessity reviews
- Achieves a 90% inter-rater reliability score related to random audits regarding the use of guidelines and accurate documentation of clinical picture
- Assists in denial management mitigation by using Medical Director/E H R
- Uses GMLOS to help manage length of stay as well as other criteria to move patient efficiently through continuum of care
- Demonstrates ongoing assessment for next level of care and actions to move patient to appropriate level (LTAC, Long term care, Hospice, Home Care etc.)
- Communicates with insurance companies to ensure accurate documentation for reimbursement.
- Coordinates and submits pertinent documentation to meet medical necessity during patients’ stay.
- Collaborates and conducts a comprehensive care plan meeting with patients, family, and interdisciplinary team (IDT) to ensure all discharge needs are met.
- Develops individualized discharge care plans in EMR.
- Maintains current with changes to Patient Driven Payment Model (PDPM) for maximum reimbursement.
- Consistent communication with Managed Care companies regarding continued stay, covered days and any discrepancies.
- Notifies appropriate staff of any discrepancies with documentation requirements.
- Incorporates input from patient and family to ensure an individualized plan of care is in place to best fit the patient’s needs while on TCC and upon discharge.
Performs and executes discharge planning within the first 24 hours of patient stay
- Performs accurate and timely screening of patients for discharge needs
- Develops sound and reliable discharge plans incorporating risk for readmission assessment in discharge needs and support structure
- Includes all stakeholders in the discharge plan to ensure plan is sound and fully communicated
- Ensures assessments and plans documented in EMR and other required documents
- Participates in multidisciplinary rounding process as requested
- Works collaboratively with all caregivers in the continuum of care to ensure sound and timely discharge plan
- Manages LOS and resource utilization
- Demonstrates strong understanding and mastery of community resources
- Possesses strong discharge planning assessment skills
- Communicates well and frequent with patients and families
- Performs readmission screens and takes action to mitigate readmission risk (use of post discharge resources, medication planning, etc.)
- Ensures referrals to other needed disciplines as deemed by assessments (physical therapy, dietary) are made timely early in stay
- Works collaboratively with nursing and other members of the care team, to ensure issues that Case Management identifies, are included in the plan of care
- Organizes and leads multidisciplinary care conferences as necessary to facilitate plan of care progression.
- Adheres to CMS COP: Discharge Planning
Assist in facilitation of organizational and unit based quality initiatives and documentation in EMR.
- Incorporates key quality assessment points with daily rounding on patient load
- Institutes corrective actions when opportunities for improvement are noted during rounds or identified via other ways (service recovery efforts or reporting timely to manager or appropriate parties; institution of safety measures if not in place or identified)
- Performs screening to see if core measures are met and initiates actions to get required actions or documentation completed (asking responsible party to complete etc.)
- Daily use of data to assist with identification of readmission and risk sharing population. Also identified other risks such as falls, wounds, pain etc. Once identified works collaboratively with care team to initiate measures to mitigate risk
- Ensures accurate documentation by physician for all components related to CMS Certification both for admission and continued stay
- Collaborates with Clinical Documentation Specialist to ensure documentation is present to support diagnosis
- Collaborates with RAC/Denial Management Coordinator to ensure documentation of medical necessity is present in medical record, for both admission and continued stay, to assist with mitigating denial management for all payers
- Documents all Discharge Planning components accurately in EMR
- Assist with documentation in EMR to support quality initiatives
- Assist with audits for medical necessity documents as requested
About Us
Find it here. Discover the job, the career, the purpose you were meant for. At Carle Health, we're committed to fostering a workplace where every team member feels valued, respected and empowered, where passion and purpose come together to positively impact the lives of our patients and our communities. Find it all at Carle Health.
Our nearly 17,000 team members and providers work together to support patient care across central and southeastern Illinois. We’ve grown to include eight, award-winning hospitals and a multispecialty provider group with more than 1,500 doctors and advanced practice providers. We’re developing the next generation of providers and healthcare professionals through Carle Illinois College of Medicine, the world’s first engineering-based medical school, and Methodist College. Carle BroMenn Medical Center, Carle Foundation Hospital, Carle Health Methodist Hospital, Carle Health Proctor Hospital, Carle Health Pekin Hospital, and Carle Hoopeston Regional Health Center hold Magnet® designations, the nation’s highest honor for nursing care. We offer opportunities in several communities throughout central Illinois with potential for growth and life-long careers at Carle Health.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class. Carle Health participates in E-Verify and may provide the Social Security Administration and, if necessary, the Department of Homeland Security with information from each new employee's Form I-9 to confirm work authorization. | For more information:
Compensation and Benefits
The compensation range for this position is $35.87per hour - $58.37per hour. This represents a good faith minimum and maximum range for the role at the time of posting by Carle Health. The actual compensation offered a candidate will be dependent on a variety of factors including, but not limited to, the candidate’s experience, qualifications, location, training, licenses, shifts worked and compensation model. Carle Health offers a comprehensive benefits package for team members and providers. To learn more visit careers.carlehealth.org/benefits.
