Care Management Representative

I.
Summary of Position This job description provides information essential to understanding the scope of the position and is not intended to be an exhaustive list of skills, efforts, duties, responsibilities or working conditions associated with the position This nursing position is responsible for providing care coordination, comprehensive discharge planning, daily rounding with interdisciplinary team, utilization review/management, readmission avoidance action plan strategies, care transitions coordination and strategic plans for the Collaborative Practice Groups under the guidance of the Director of Care Management.
The Care Management Representative participates in a collaborative process which assesses, plans, implements, coordinates, monitors and evaluates the options and services for a patient's individual health needs under the Scope of Service for the department.
Provides linkages, referrals, coordination, and follow-up for identified patients and those who qualify for Health Homes.
Coordinates follow up appointments with patient's Primary Care Physician /Patient Center Medical Home/ Health Home based on risk status.
Responsible for daily operations to coordinate high quality cost effective care at Saratoga Hospital.
Responsibilities include meeting all compliance and regulatory agency guidelines.
Strives to incorporate the philosophy and mission of the hospital and its goals of rendering quality care management services.
Is a critical thinker and problem solver to resolve challenges and barriers to achieve care management goals and safe disposition of patient across the care continuum.
Possesses strong interpersonal skills to work with care management team and other interdisciplinary team members to reach quality outcomes.
Care Management average patient case load is 20-25 pts:1 care manager and may have assistance with other team members such as social workers on dual plans and nursing facility placements.
II.
Primary Job Responsibilities These requirements are representative, but not all-inclusive, of the knowledge, skill, and ability required of the position.
Primary job responsibilities constitute approximately 90% of the positions work.
To be successful, individuals must be able to perform each essential responsibility satisfactorily.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions outlined in this position description.
1.
Assesses patients within service line to identify needs according to established guidelines & Care Management policies.
Coordinates care, monitors patient progress daily, and establishes discharge goals based on the care plan and patient outcomes with input from the interdisciplinary team.
Completes CM assessments and LACE tool readmission risk determinations for identified patients such as those with chronic disease (CHF, RF, COPD, MI, PN & DM as well as those previously re-admitted or identified at risk patients) 2.
Participates in daily rounds with physicians and team.
Develops discharge goals based on patient progress and anticipated LOS targets.
Works to minimize discharge delays and achieve appropriate discharge times.
3.
Documents the care plan and goals in the medical record according to policy guidelines.
Utilizes MCG- Milliman criteria to identify severity of illness & intensity of service for appropriate utilization management and 1st level criteria reviews.
Documents required data in Allscripts and follows the Care Management Plan Policy for utilization review & management.
Follows through with the attending physician regarding patient status and level of care.
As needed consults internal and external physician advisor for 2nd level reviews.
4.
Initiates community resource referrals as needed based on patient choice and post-hospitalization needs for discharge and transfer.
Coordinates interdisciplinary collaboration to achieve patient safety and a safe discharge plan.
Maintains a working knowledge of the resources available in the community and requirements of government payers and managed care organizations.
Provides appropriate linkages, referral coordination, and follow up for identified patients and those requiring Health Homes and other transitions.
5.
Advocates for the patient's and family's needs.
Arranges patient care conferences as needed to facilitate complex discharge planning, improve communications, and achieve quality patient outcomes.
6.
Participates in the goals and activities of the Collaborative Practice Groups, Magnet Councils, Interdisciplinary Committees and/or Utilization Management Committee.
Develops and implements interdisciplinary care plans as needed for servicelines and improved patient outcomes.
Takes an active role in committee membership, agenda planning, case study presentations and committee reports.
7.
Serves as a resource to physicians, patients/families regarding insurance coverage/reimbursement.
Adheres to established guidelines for working with insurance case managers and utilization specialists.
Monitors daily insurance logs for accuracy and appropriate patient status.
Appropriately identifies patient's level of care and collaborates with physician regarding status changes to ALC (Alternate Level of Care), skilled & custodial care for Medicare patients.
Completes HINN notices and documentation requirements for Medicare regulations as required.
Issues "Important Medicare Message" (IM) as required 24-48 hours prior to discharges of Medicare and/or Management Medicare patients.
III.
Additional Responsibilities Under the direction of the Director of Care Management may have opportunities to work with legal counsel and other agencies such as Regulatory Agencies and Mental Hygiene Legal services to achieve planning requiring legal guidance to achieve safe patient outcomes.
IV.
Supervisory Responsibilities Leads by example in all care management department team responsibilities according to the Mission and Vision of the hospital.
Leads Collaborative Practice Group meetings and agenda planning with Director input based on Organization Strategic Goals.
As with all care management staff, the Care Manager will support the goals of the Care Management team for safe care coordination and transition for patients.
Cross-coverage of other Care Management assignments may be required due to unexpected illness and coverage needs, as determined by the manager and/or director.
V.
Minimum Qualifications Education, Training & Experience BSN preferred (or matriculating towards degree achievement) Minimum of 3 years acute care hospital experience Knowledgeable of New York State and Federal Entitlement Programs and regulatory requirements.
Certifications / Licensure Current RN nursing license PRI Certification preferred CCM Certification preferred VI.
Required Skills and Attributes Able to function independently Able to prioritize and multitask Leads and works effectively with social work team and care management department Strong interpersonal skills, able to critically think and intervene in crisis and complex family dilemmas.
Effective verbal and written communication skills Skilled in Meditech programming and Microsoft products Open to constructive feedback Possesses critical thinking skills for problem solving VII.
Patient Populations Served (Check all that apply) X Neonates 1- 30 days X Adults 19-70 years X Infants 30 days – 1 year X Geriatrics 70 + X Children 1-12 years No patient contact X Adolescents 13-18 years VIII.
Work Environment/Working Conditions The physical demands described are representative of those that must be met by an employee to successfully perform the essential functions of the job.
Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions.
Salary Range: $33.
60 - $56.
50 Pay Grade: N14 Compensation may vary based upon, but not limited to: overall experience and qualifications, shift, and location.
Location: Saratoga Hospital · Care Management Schedule: Salaried Full-Time, Day shift, 8 am to 4:30 pm