Acute Care Nurse Case Manager
HealthSpring - Baltimore, MD

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The Acute Care Manager (ACM) role [formerly the on-site discharge planner] performs the day- to-day on site functions of concurrent review and post discharge care coordination in his/her assigned hospital sites. This role requires multidisciplinary collaboration. The ACM reviewer monitors the utilization of care on-site by being proactively involved in chart review, through interactions with the covered beneficiary, attending and primary care physicians, care managers of the hospital, the Bravo Health (BH) Institutional Based (IB) program staff, BH Advanced Care Center (BHACC) hospitalists and the BHACC centers and discharge planning coordinators. Responsibilities may vary based on facility contract terms and assignmentResponsible for providing support to patients, their families, and physicians in addressing medical and social concerns. Educates patients and families to make informed personal health care decisions. Facilitates communication between patient, physician, health plan, and community.

Required Skills

DUTIES AND RESPONSIBILITIES :
Reviews the inpatient chart of every patient admission concurrently and based on the severity of the illness and intensity of the patient services in her/his assigned hospital.

Refers cases and prepares for discussions/rounds with the Bravo Medical Director to assess and address appropriateness of the medical care rendered using relevant InterQual criteria and Medicare guidelines as appropriate.

Notifies the Primary Care Provider (PCP) of admissions from his/her panel of members if the PCP is not the admitting physician in order to enhance the clinical information available to the PCP and the admitting physician.

Notifies the Bravo Health Nurse Practitioner (NP) responsible for the care of the Institutional Based Bravo Health member admitted or discharged to/from his/her assigned hospital and receives additional necessary clinical information from the NP to expedite the care of the member.

Collaborates with the attending physician or hospitalist when information obtained from the medical record review does not meet admission or concurrent review criteria and when discharge planning needs are identified.

Interviews and completes Bravo Health Risk Assessment tool for members during inpatient stay based on member triage criteria e.g. Bravo members known to complex care at the BHACC, members at high risk of readmission, members hospitalized more than seven (7 days). Identifies and refers individuals based on risk assessment for case management.

Monitors progress and readiness for discharge.

Collaborates with facility care/case managers and applicable Bravo Health team members to prepare for safe discharge. Facilitates and coordinates discharge planning by ensuring the Bravo member has access to ordered alternate level of care placements (e.g. Rehab, SNF), durable medical equipment, home health, prescriptions, and follow up appointments to their PCP and the Bravo Health Advanced Care Center (ACC)as applicable.

Completes system authorizations, documentation and updates as applicable. Issues or coordinates with the facility UM representative to issue notices of non-coverage and appeal rights as applicable.

Prepares and participates in the BHACC interdisciplinary conference /rounds weekly at the applicable BHACC.

Acts as the liaison between their assigned facility, Bravo Health, the BHACC , Bravo Hospitalists and the Bravo Health medical directors regarding census and for issues requiring intervention.

Identifies coordination of benefit opportunities and identifies opportunities such as avoidable admissions, alternate levels of care, physician-member interventions and transition of care concerns.

Assists the Manager/Management Health Services in communicating Bravo Health strategy or processes and resolving conflicts or issues between Bravo Health and their assigned facility.

Facilitates the transfer of clinically stable members from non-contracted facilities to contracted facilities by contacting the member’s PCP or arranging with the Bravo Health medical director for a contracted provider to accept the transfer of care of the member.

If needed, provide on call availability for Bravo Health admissions either to contract or non contracted facilities.

Contributes and adheres to Bravo Health’s, a Health Spring company, overall mission, vision, and values statements.

Participates in optional and mandatory in service training sessions.

Performs other duties as needed by the Manager, Health Services.

Under general supervision, responsible for identifying high risk patients for case management intervention and coordinating the delivery of cost-effective, quality-based health care services for health plan members by development and implementation of alternative treatment plans that address individual needs of the member, their benefit plan, and community resources. Directs intervention with moderate to high risk members, and provides support and oversight to other team members managing low risk members. Interfaces with providers of medical services and equipment to facilitate effective communication, referrals, development of discharge planning and alternative treatment plan development. Initiates contact with patient/family, physician, and health care providers/suppliers to discuss the alternative treatment plan and conducts on-site or in-home evaluations as necessary. Monitors, evaluates, extends, revises or closes treatment plans as appropriate. Evaluates cases for quality of care. Communicates case management decisions. Understands and follows policies and procedures and produces and submits reports in a timely manner. Handles high acuity and complex cases. Serves as a professional resource to other Case Managers. Initiates and leads the multi-disciplinary care planning process.

Required Experience

Minimum 2-3 years of acute adult/geriatric inpatient clinical experience; ICU/ED experience preferred AND minimum 1-2 years post-acute/home care or care coordination experience required

Registered Nurse (RN) with active, unrestricted, current license in applicable state

Proficient in using lap top computer using windows based software including MS Word

Ability to learn medical authorization QNXT claims software

Capability of working in a team-oriented, dynamic environment

Ability to be flexible and adaptable in a fast paced work environment

Previous health plan experience with concurrent review, discharge planning or care coordination preferred

Minimum Requirements: Current licensure as a Registered Nurse (RN) or licensed mental health practitioner in applicable state or active license in a state allowing “multistate privilege to practice”. Three or more years experience in clinical and case management.

Preferred Requirements: Certified Case Manager.

HealthSpring is an EEO/AA employer

HealthSpring - 20 months ago - save job - block
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