CARE MANAGER
White Plains Hospital - White Plains, NY

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Associate's Degree
Professional License Required
Previous Hospital Experience Required

The Care Manager (CM) coordinates the clinical and financial plan for assigned patients. He/She will perform overall utilization management, resource management, discharge planning and post-acute care referrals and authorizations. He/She will also work with multi-disciplinary team in resource management, discharge planning and care facilitation. Promotes a cooperative and supportive relationship as liaison with patient, family, facility staff, physicians and funding representatives. Ensures continuity in the delivery of services across departments.

Job Responsibilities:
See below. Performs other duties as assigned.

ESSENTIAL ROLE AND RESPONSIBILITIES:
Patient Care / Patient Education
  • Assumes an active role in the planning and implementation of educational needs of assigned patients with direct care team
  • Coordinates assigned patients’ clinical plan, discharge plan of care, and targeted LOS with appropriate care team and communicates plan to patient/family
  • Communicates post-acute services and payer requirements to patient/family as needed according to current understanding of care needs
Discharge Planning
  • Initiates discharge planning on admission and ensures documentation is completed and updated regularly
  • Identifies the estimated discharge date upon admission and documents for LOS management
  • Collaborates with patients, caregivers, healthcare agencies and payers to plan and implement a safe discharge
  • Identifies barriers to discharge and works with the multi-disciplinary team to expedite care, monitor length of stay, and facilitate discharge
  • Addresses complex clinical and social situations efficiently to avoid unnecessary delays in discharge
  • Re-evaluates/revises discharge plan as patient’s clinical condition warrants
  • Develops alternative discharge plan(s) in anticipation of changes in patient’s post acute needs
  • Documents all Avoidable Days
  • Coordinates post-acute service referral needs through the “resource” center
  • Uses Milliman to determine appropriate level of care (skilled, rehab, etc) and obtains needed payor authorizations for post acute care
  • Obtains the support of the social worker for complex discharges and placements
Care Facilitation
  • Develops, manages, and drives clinical plan of care with physician and assigned unit or service multi-disciplinary care team
  • Works collaboratively and maintains active communication with physicians, nursing and other care team members to ensure ti mel y patient management
  • Coordinates patient care across units to reduce fragmentation of care and addresses/ resolves system issues impeding progress, including but not limited to pending orders or procedures, waiting on test results, needing MD discharge order
  • Leads weekly outlier case reviews and r uns daily LOS rounds with assigned care team to manage progress
  • Expedites throughput of the complex patient to meet overall LOS, quality and resource utilization goals
  • Screens & refers patients for social worker intervention
Utilization Management
  • Performs clinical review on admission, and/or continued stay to determine appropriate level of care (Inpt, Obs, etc)and questions MD placement of patient onto unit when LOC criteria not meet
  • Follows payor specific requirements to obtain and document authorizations
  • Reviews medical record daily to ensure patient continues to meet level of care requirements
  • Ensures that medical record documentation supports level of care
  • Works with Physicians and Clinical Documentation Specialists to obtain documentation to support current level of care
  • Updates level of care as needed
  • Expedites discharge planning for patients who no longer require hospital services
  • Communicates with physicians and nursing regarding resource utilization, LOS, level of care, and post acute care placement
  • Takes leadership role in concurrent denial process
  • Obtains Consent to Appeal on behalf of Member for any concurrent denials
  • Documents avoidable days and communicates , if needed regarding any denials for assigned patients
Other
  • Acts as resource to clinical and finance teams for level of care, insurance coverage issues, specific payer and government policies and post-acute services coverage and availability
  • Promotes patient safety
  • Supports CORE measures information for TJC requirements
Education, Training, Licensure and Experience Requirements

  • BSN or related Bachelor's degree preferred
  • 5 years clinical experience required
  • Previous case management experience preferred
  • Knowledge of healthcare financial and payor issues preferred
  • Knowledge of state, local, and federal programs preferred
  • Use of Milliman/InterQual criteria preferred Registered Nurse (R.N) required C.C.M. (Certified Case Manager) certification preferred

White Plains Hospital - 19 months ago - save job - block
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White Plains Hospital is a voluntary, not-for-profit health care organization with the primary mission of offering high quality, acute...