RN - Case Manager - PRN in Fort Mohave, AZ at Valley View Medical Center

Date Posted: 9/6/2018

Job Snapshot

Job Description

Valley View Medical Center

Patient care assignment may include neonate, pediatric, adolescent, adult and geriatric age groups; with the supervision of the Director of Case Management, coordinates all systems/services required for an organized, multidisciplinary, patient centered care team approach, and assure quality, cost-effective care for the identified patient population. This position is responsible for initial utilization and discharge assessment and completes concurrent utilization review and monitor progress through the acute care continuum. Manages the course of treatment of patients, coordinating care with physicians, nurses and other staff ensuring quality patient outcomes are achieved within established time frames and with efficient utilization of resources. Conducts initial and ongoing assessments, determine and manage outcomes, ensure continuity of care through discharge planning, utilization of resources and analysis of variances. Functions as a contact person for patient, family, health care team members, community resources and employees as necessary. Ensure adherence to Hospitals and departmental policies and procedures. Analyzes patient records to determine legitimacy of admission, treatment and length of stay in health care facility to comply with government and insurance company reimbursement policies. Responsibilities include Discharge planning and coordination. Facilitate improvement in the overall quality, completeness and accuracy of clinical documentation. Through concurrent interaction with physicians, coders and other health care team members will strive to ensure comprehensive medical record documentation that reflects the clinical treatment, decisions and diagnosis for all inpatients.

ESSENTIAL TASKS, DUTIES AND RESPONSIBILITIES

PRIMARY RESPONSIBILITIES:

  • Perform integrated initial and concurrent review to identify medical necessity and utilization issues.
  • Interface with external review companies and consultants, using advocacy and negotiating skills that address medical necessity and appropriateness of inpatient/outpatient levels of care.
  • Partner with the healthcare team, community resources, liaisons, and families to provide timely coordinated admission and discharge planning that is appropriate based on patient needs.
  • Match patients with appropriate internal and external resources to meet their ongoing needs, and facilitates application(s) for programs and referrals for special needs.
  • Conducts review for clinical appropriateness and level of care using evidence based criteria and works with payers to authorize care concurrently and post discharge services as required.
  • Works closely with the coding specialist to identify and update the working DRG as indicated by patient acuity.
  • Reviews medical record documentation, communicate with the attending physicians as needed to ensure the documentation represents the acuity of need of that patient to allow for appropriate reimbursement.
  • Improves overall quality and completeness of clinical documentation by performing daily medical record reviews
  • Will utilize coding and clinical expertise to identify opportunities and ensure the accuracy and completeness of clinical documentation user for measuring and reporting physician and hospital outcomes.
  • Queries physicians on specificity of procedures performed and diagnosis based on accepted coding guidelines and clinical expertise
  • Integrates factors related to quality, efficiency and cost-effectiveness in managing care and makes appropriate referrals.
  • Identify cases with potential for high risk complications and act as an advocate for the individual's health care needs

OTHER TASKS, DUTIES AND RESPONSIBILITIES

  • Participate in reporting abuse, neglect or exploitation suspected prior to hospitalization as indicated by hospital protocol.  Report findings to the appropriate agency.
  • Collects appropriate avoidable delays and other data as directed.
  • Communicates with patients, family, significant others in identifying the discharge need of the patient and any barriers in the completion of a safe discharge goal.
  • Contact attending physician to clarify patient’s medical information and discharge plans and identify potential needs
  • Develop, Review, and revise pathways for specifically identified DRG’s to meet regulatory requirements, reduce LOS, readmissions and assure documentation meets Medicare requirements to reduce the risk related to RAC’s.
  • Works in conjunction with the Directors of Quality Improvement, Medical Staff Credentialing and medical staff leadership to assure effective monitoring and successful completion of identified plans for improvement
  • Stays current with requirements of CMS Inpatient Prospective Payment Systems (IPPS), AHA Coding Clinic and Official Guidelines for Coding and Reporting related to ICD9 and when required ICD-10.
  • Reviews clinical issues with physician advisors
  • Participates in department and facility Quality and Performance initiatives
  • Makes regular reports of progress toward goals associated with clinical documentation improvement opportunities and operational improvement plans
  • Other duties as assigned.

Job Requirements

Degree / Licensure / Certification / Registration:  Valid RN license in the State of Arizona or from a Compact state with multi state privileges.

SKILL OR EXPERIENCE REQUIREMENTS:


•         3-5 years experience in an acute care hospital setting


•         Prefer Experience with case management process


•         Prefer Certification in a related field to Case Management

  •        Excellent collaboration and communication skills


•         Working knowledge of:

v  Community and governmental resources

v  Third party payer criteria and regulation, including InterQual and MCG

v  Federal and State Requirements


Equal opportunity and affirmative action employers and are looking for diversity in candidates for employment: Minority/Female/Disabled/Protected Veteran

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