SUMMARY
The Case Manager/Utilization Review assumes responsibility for assessing and directing the clinical management of patients in specific case groups for an episode of care. The CM/UR is responsible for developing and meeting desired patient care outcomes for his/her caseload based on assessment of patient care needs and on established clinical care patterns, within an appropriate length of stay and appropriate use of resources. The CM/UR, responding to complex patient care needs from admission to discharge, works productively and cooperatively in collaboration with the physician, clinical staff nurses and managers, as well as other health care professionals. The CM/UR will also function in the Utilization Review capacity, interfacing between clinical providers, healthcare payors, and the business office to ensure appropriate clinicals are created, reviewed, and sent to payors for approval.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Conducts initial screening and assessment of patients on admission including twenty-hour observations using pre-established Intensity of Service and Severity of Illness criteria. Based on admission screening, determines diagnosis related group (DRG) and appropriate length of stay (LOS).
- In collaboration with physicians and other health care professionals, plan, organize, directs and evaluate the continuum of patient care, The Case Manager evaluates interventions of physicians and other health care disciplines based on care pathways, severity of illness and intensity of service criteria.
- Facilitates the patient's movement throughout the hospital system in cooperation with the clinical staff, other healthcare professionals and the physician. The Case Manager's role centers on coordinating, negotiating, procuring and managing the plan of care to facilitate cost effective quality of care and patient satisfaction. She/he also develops possible alternative to care plans.
- Conducts review of patient records according to established utilization review criteria to ensure appropriateness of hospitalization. Communicates with Medicare, Medicaid and third party payers to ensure coverage for services.
- Explores strategies to reduce the length of stay and resource consumption; implements and documents results. Identifies opportunities for system improvements.
- Prioritizes workload and focuses on problem cases; communicates with physician, nurses, department directors, and other health care providers, both internal and external.
- Documents on worksheets, assessment forms, and progress notes on a timely basis and as per policy.
- Facilitates appropriate referral consultation based on patient assessment, follow-up of required or delayed testing, care pathway and results of physician intervention.
- Coordinates discharge planning, including assessment of discharge needs resource availability and communication of patient's needs among team members and family's.
- Identifies and reports any quality, risk management or utilization issues the Director of Case Management.
- Facilitates and coordinates patient care team conferences. Communicates utilization issues; discharge planning reviews and variances of care.
- Completes all admission, discharge and psychosocial assessments on a timely basis. Completes monthly statistical log to reflect case activity.
- Assists the Director of Case Management in the investigation of over and underutilization cases, implementation of corrective measures and chart review per medical staff request.
- Performs other related duties as assigned.
- Demonstrates working knowledge of payer requirements.
- Directs staff nurses improvise documentation that relates to the patient’s condition and orders/services obtained from the physician.
- In the absence of the case manager, director serves in a leadership role by covering the department regarding staffing, issues or concerns.
- Demonstrates awareness of regulatory requirements, including but not limited to, HFAB, IDPH, CMS.
- Conducts initial screening and assessment of patients on admission, including 24 hour observations using preestablished Intensity of Service and Severity of Illness criteria. Based on admission screening, determines diagnosis related group (DRG) and appropriate length of stay (LOS).
- In collaboration with physicians and other health care professionals, plan, organize, direct, and evaluate the continuum of patient care.
- Evaluates interventions of physicians and other health care disciplines based on care pathways, severity of illness, and intensity of service criteria.
- Serves as a coordinator, negotiator, procurer, and manager of the plan of care to facilitate cost effective quality of care and patient satisfaction.
- Identifies and reports any quality, risk management, or utilization issues to the Director of Case Management.
- Other duties as assigned.
COMPLIANCE RESPONSIBILITIES
- Understands and adheres to Loretto Hospital’s compliance standards as they appear in the Compliance Policy, Code of Conduct and Conflict of Interest Policy.
- Keeps abreast of all pertinent federal, state and Hospital regulations, laws, and policies as they presently exist and as they change or are modified.
- Ensures that the staff are trained and evaluated on their knowledge of and adherence to compliance policies and procedures specific to their jobs.
JOB REQUIREMENTS
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
1. High School Diploma or GED required
3. Minimum of two years’ experience in Medical/Surgical, Psychiatry and/or Critical Care.
4. At least one to two years progressive experience in utilization management, discharge planning or case management.
5. Strong communication skills, utilizes problem-solving process, acts as a team leader, demonstrates good work ethic, demonstrates good nursing assessment skills, maintains confidentiality, demonstrates flexibility and analytical skills.
6. Has working knowledge of resources available in the community for the patient and families.
7. Has basic knowledge of criteria sets.
8. Demonstrates working knowledge of payer requirements
The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.
For purposes of the American with Disabilities Act, “Job Duties” are essential job functions.
PHYSICAL DEMANDS
While performing the duties of this job, the employee is frequently required to sit, stand and walk as well as occasionally stoop, kneel, crouch or crawl. Using proper body mechanics, the employee may be expected to lift, pull, push or move patients and/or equipment. Fine motor skills are required when using hands and fingers to handle, feel or reach. Normal or corrected vision, hearing and ability to speak are necessary. Specific vision abilities required include close vision, sharp eye focus and ability to distinguish colors. There will be periods of stressful intense concentration with more than average pressure used in a variety of problem solving situations.
Loretto Hospital Chicago, Illinois, USA Office
645 S Central Ave, Chicago, Illinois, United States, 60644 5059
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