The mission of Mercy Health is to extend the healing ministry of Jesus by improving the health of our communities with emphasis on people who are poor and under-served.
SUMMARY OF JOB RESPONSIBILITIES:
The case manager coordinates the care and service of selected patient populations across the continuum of illness;
Promotes effective utilization and monitoring of health care resources; and leadership role with the interdisciplinary team to achieve optimal clinical, resource, and quality outcomes.
Qualifications - Minimum
Graduate of an accredited School of Nursing (BSN/BS required).
Current R.N. license in Ohio. CPR certified.
Case Management Certification desirable.
Experience in Performance Improvement, Utilization Management, Case Management and/or Discharge Planning strongly preferred.
5 years acute care experience with a variety of patient populations; demonstrated leadership in nursing or hospital performances improvement initiatives.
Demonstrated leadership experience.
KNOWLEDGE AND SKILLS:
Knowledge and skill required to perform the job responsibilities.
Understands and integrates clinical information from multiple disciplines.
Computer skills including Windows and Windows-based applications.
Knowledge of DRG assignment desirable.
PRINCIPAL JOB ACCOUNTABILITIES:
Supports the achievement of the Humility of Mary Health Partners mission and living of its values.
Models supportive behaviors.
Supports collaboration, Performance Improvement processes, inter-disciplinary work teams, and partnership relationships with customers.
Responsible for own professional/personal growth and development.
Communicates effectively with all departments & employees of the organization and other customers.
Promotes stewardship of resources while maintaining or improvement quality of care.
Exhibits ownership for the success of the organization.
Effectively engages in two-way dialogue and problem solving.
Works independently to meet operational objectives.
Receives, investigates and appropriately reports and responds to problems/incidents that involve safety and compliance issues.
Holds self, employees and co-workers accountable for keeping patient safety the first priority in performing the essential duties of their jobs.
Upholds resources in a manner consistent with the organizational plan.
Participates in HMHP’s recruitment and retention goals.
Maintains department resources in a manner consistent with department budgets and departmental activity.
Understands cost per unit of service.
Accurately identifies patients who meet the guidelines for case management.
Develops, implements, monitors and modifies the plan of care for the patient through a
Collaborative and interdisciplinary team process.
Locates community resources and links the patient to the most appropriate ones.
Assesses the patient’s physical, psychological, functional, social, environmental, and financial status and goals.
Evaluates the patient’s formal and informal support systems.
Assesses family/caregiver coping styles, and the ability of the family/caregiver to support and participate in the planning of care.
Utilizes the data collected in the assessment process to formulate and document interdisciplinary outcomes (goals) to be achieved.
Continually assesses outcomes and goals for workability, manageability, cost effectiveness, and updates the plan as needed.
Evaluates professional activities to assure that the planned services are being delivered and that they meet the stated outcomes/goals.
Monitors the patient’s progress towards outcomes and makes recommendations as to the continuation of services.
Acts as a leader and a liaison among the disciplines.
Facilitates communication with all providers of care, and facilitates access to care.
Assumes responsibility for cost effectiveness.
Is knowledgeable of disease processes, treatment protocols, and pharmacological management to assure appropriate care delivery.
Researches alternative methods and practices to enhance care delivery and to move the patient to desired outcomes.
Provides hands-on patient care and teaching as appropriate.
Is responsible and accountable for one’s work, and results achieved.
Utilization Management/Discharge Planning
Initiates an integrated review within 24 hours of admission. Performs a chart review daily for
Concurrent utilization and discharge planning.
Understands payer principles, terminology of managed care, and the goals of the managed care
Ascertains that the hospitalization is necessary and beneficial.
Assures that the hospital is able to provide the necessary care needed to meet the physical/medical needs of the patient.
Certifies all admissions and continued stays for medical necessity by documenting either InterQual or Milliman and Robertson criteria in the computer system.
Evaluates all orders and diagnostic studies to assure that there are no delays in the initiation of orders, reporting of test results, or addressing abnormal results.
Identifies patients who are appropriate for a critical pathway, that the patient is on the pathway and that the patient and family/caregiver is in agreement with the plan.
Assures that ongoing discharge planning is in place, and that the patient and family/caregiver is in agreement with the plan.
Maintains a knowledge of community services and agencies.
Advocates for the patient and/or hospital as appropriate when dealing with insurance companies/third party payers.
Investigates, pursues, and at times, brokers for all the benefits that can be obtained through the patient’s healthcare plan.
Identifies, tracks, documents, and analyzes clinical and/or system variances, and is proactive in developing corrective approaches to improve care or prevent delays.
Is knowledgeable of Medicare compliance standards and assures that these standards are met.
Utilizes the physician advisors when appropriate.
Identifies patients who are appropriate to receive a Hospital Initiated Notice of Non-Coverage and is knowledgeable of the process for delivery to the patient or family/caregiver.
Documents/reports insurance denials appropriately and assists with the appeal process.
DRG Assurance/Performance Improvement
Understands the knowledge and principles of the hospital DRG assurance program.
Assigns a working DRG to all patients admitted to the hospital having a DRG payer.
Identifies secondary diagnoses through meticulous chart analysis.
Prompts physicians for additional documentation when appropriate, and documents these prompts along with the outcome of the prompt in the appropriate area.
Is knowledgeable of the Case Mix Index and ways of improving.
Collects data and completes focus studies concurrently on all Medicare studies or service line/pathway projects.
Is accurate, consistent and concurrent in documenting insurance and other data elements in the appropriate case management computer tools.
JOB ACCOUNTABILITIES – Other:
Able to accept multiple tasks from a variety of sources and work on these tasks to produce timely
and favorable outcomes.
Effectively organizes daily work to meet priorities and to accommodate fluctuations in workload.
Documents all reviews in the case management computer system.
Develops appropriate educational programs for identified departments or staff to facilitate the achievement of quality patient outcomes and to inform of managed care/case management concepts or initiatives.
Develops effective communication with staff, physicians, patient/families/caregivers, and other members of the healthcare team.
Collaborates with admitting registration/verification or finance departments to address or resolve any billing issues.
Regularly attends and participates in outlier or discharge planning rounds to address specific patient needs or complex discharge planning issues.
Maintains patient confidentiality and is knowledgeable of the HIPAA guidelines for patient
Actively seeks to participate on committees, task forces, and other work groups.
Researches and seeks opportunities for improvement in the delivery process, or specific patient care problems.
Actively seek ways to promote the work of the department by mentoring students or new employees, organizing in services, participation in job or recruitment fairs, teaching classes or sharing of articles.
Represents the hospital and the department with a positive and professional attitude toward physicians, patients, insurers, and outside reviewers.
Maintains a positive attitude in the delivery of quality patient care within the healthcare institution.
Uses the appropriate avenues and approaches to advocate for changes within the department and the institution.
The above statements are only meant to be a representative summary of the major duties and responsibilities performed by incumbents of this job. The incumbents may be requested to perform job-related tasks other than those stated in this description.
Hours per pay period: 80
Hours: 7:30am to 4:00pm
Rotating weekend and holiday coverage.
Shift and Job Schedule
Job Shift: Days/Afternoons, Job Schedule: Full-Time
Equal Employment Opportunity
It is our policy to abide by all Federal and State laws, as well as, the requirements of 41 CFR 60-1.4(a), 60-300.5(a) and 60-741.5(a), prohibiting discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibiting discrimination against all individuals based on their race, color, religion, sex, sexual orientation, gender identity, or national origin.