CARE MANAGER
White Plains Hospital - White Plains, NY

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Associate's Degree
Professional License Required
Position Summary:

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

About this company
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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...