The Case Manager is
responsible for the interdisciplinary coordination of care for a
designated patient population. The Case Manager performs reviews of
all inpatient admission records to ensure proper utilization of
hospital resources and determination of admission for appropriate
level of care. Assesses and identifies discharge needs and
coordinates appropriate discharge plan. Works collaboratively with
the interdisciplinary team to facilitate achievement of desired
financial and quality outcomes. The Case Manager will also maintain
and enhance payor relationships. Performs other related duties as
assigned or requested.
Admission Data Collection and
• Assesses, plans, monitors, and coordinates plan of care from
pre-admission to community re-entry through the implementation of
case management standards and processes.
• Assesses the individual’s personal and medical history, current
status, diagnosis, prognosis, and the proposed treatment plan.
• Promotes and utilizes the appropriate level of care for the
patient and refers to other facilities as needed.
• Adheres to contract agreements and specific criteria.
• Serves as a liaison with payor source points of contact to verify
and guarantee coverage and identify items required to process the
claim for service.
• Assists patient and or caregiver in developing realistic goals to
direct the treatment regimen.
• Proactively communicates with payor source to explore coverage
solutions (flex benefits, out of contract, etc.).
Planning, Implementation &
• Promotes optimal outcomes for the patient within the boundaries
of the diagnosis.
• Coordinates and facilitates interdisciplinary team (IDT) meetings
and plan of treatment.
• Meets with patient, family, and IDT to facilitate “continuity of
• Implements utilization review process and continuously evaluates
the appropriate level of care with the interdisciplinary team and
payor, and patient/caregiver(s). Proactively obtains authorization
for any extension of service of LOS.
• Coordinates the discharge plan with the IDT and providers.
• Monitors expense versus revenue for caseload on a daily
• Proactively collaborates with the health care team, payors,
community agencies, providers and legal representatives to ensure
continuity throughout the continuum.
• Serves as a liaison with the treatment team and the primary care
physician, referring physician, medical director,
patient/caregiver(s), and other parties as appropriate.
• Promotes effective communications among treatment team members,
patient/caregiver(s), primary care physician, referring physician,
medical director, and payor.
• Participates in care conferences, family conferences, etc. when
• Educates and supports the individual/family to be empowered and
self-reliant in being advocates for themselves.
• Uses the mechanism of early referral to promote and provide
optimum care and cost containment.
• Represents the individual’s best interests through assisting in
finding necessary funding, offering treatment alternatives, and
• Continuously reviews and evaluates the patient’s progress, as
reflected by the goals defined in the treatment plan.
• Uses appropriate auditing processes and tools to ensure
department and treatment efficiency.
• Participates in performance improvement evaluation processes with
particular emphasis on results-oriented treatment.
• Maintains professional growth in case management by: attending
continuing education opportunities; reviewing pertinent
professional literature; maintaining knowledge of current community
resources; and reviewing and being familiar with the managed care
marketplace to determine managed care growth potential,
opportunities, penetration, service trends, relationships,
Education and Training: RN
licensure in the state where the hospital resides preferred.
Current BLS certification required.
Experience: Three to five
years of inpatient experience, preferably in an acute, IRF or LTACH
Knowledge, Skills, and
• Excellent clinical and assessment skills.
• Effective education/presentation skills.
• Excellent written and oral communication skills.
• Effective crisis management skills.
• Effective team leadership skills.
• Knowledge of payment/reimbursement systems.
• Knowledge of patient rights and commitment to patient
• Ability to collect, document, and analyze data.
• Understanding of claims submission process.
• Word processing and data entry skills.
• Network access to community, state, and national resources and
health services organizations.