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Job Summary 

The Case Manager, RN provides comprehensive care coordination of services as a member of the interdisciplinary care team and provides discharge planning for a designated patient population. Consistently exercises discretion and judgment to assess, analyze, interpret and implement interventions to facilitate transitions of care. Position will assess, coordinate, facilitate and negotiate services and resources for a designated patient population in order to achieve desired clinical and financial outcomes as directed by Excela Health Systems. Works in collaboration with the patient's healthcare team to move the patient through the continuum of care. 

Essential Job Functions

• Maintains professional and technical knowledge by attending education workshops; reviewing professional publications; establishing personal networks; participating in professional societies.
• Assures quality of care by adhering to therapeutic standards; measuring health outcomes against patient care goals and standards; making or recommending necessary adjustments; following system/hospital and nursing division's philosophies and standards of care set by state board of nursing, state nurse practice act, and other governing agency regulations.
• Protects patients and employees by adhering to infection-control policies and protocols, medication administration and storage procedures, and controlled substance regulations.
• Documents patient care services by charting in patient and department records.
• Maintains continuity among nursing teams by documenting and communicating actions, irregularities, and continuing needs using Nurse Knowledge Exchange techniques.
• Maintains patient confidence and protects operations by keeping information confidential.
• Implements standard work, clinical protocols and patient care pathways.
• Ensures safe and effective transitions of care that help to promote positive health care outcomes for Excela Health patients.
• Assesses, plans, implements coordinates, and monitors and evaluates options for patients, their families, caregivers and the health care team, including providers, to promote effective care coordination outcomes.
• Manages transitions of care effectively as one of the critical components to reducing readmissions and poor health outcomes. Provides crisis management for clients; makes linkages for interventions as appropriate.
• Initiates care coordination strategies that are evidence-based and outcome focused.
• Implements standard work, clinical protocols and patient care pathways.
• Identifies patient care requirements by establishing personal rapport with potential and actual patients, and other persons in a position to understand care requirements.
• Establishes a compassionate environment by providing emotional, psychological, and spiritual support to patients, friends, and families.
• Promotes patient's independence by establishing patient care goals; teaching patient/family to understand condition, medications, and self-care skills; answering questions.
• Maintains safe and clean working environment by complying with procedures, rules and regulations; calling for assistance from health care support personnel.
• Demonstrates competencies of clinical reasoning and critical-thinking skills for managing complex and high-risk patients while simultaneously assuming the patient advocate role to ensure conflict-free, unbiased and culturally competent care.
• Assures care coordination that takes into account patients' values, needs, preferences and their choice to self-direct care.
• Puts the patient at the center of all care decisions and is an essential driver to ensuring that patients get the right care, in the right setting, at the right time.
• Effectively manages transitions involving comprehensive planning, targeted outreach and the timely transfer of information between parties critical to the transition. Manages transitions of care effectively as one of the critical components to reducing re-admissions and poor health outcomes.
• Facilitates the flow of care to expedite appropriate discharge and prevent readmissions.
• Assumes the leadership role in achieving outcomes and making the health system work for the patient.
• Brings access, understanding and knowledge of the community and the resources to support management of chronic illness.
• Resolves patient problems and needs by utilizing multidisciplinary team strategies.
• Maintains a cooperative relationship among health care teams by communicating information; responding to requests; building rapport; participating in team continuous quality improvement and problem-solving methods.
• Contributes to team effort by accomplishing related results as needed.
• Implements effective care coordination strategies that are evidence-based and outcome focused.
• Ensures operation of equipment by completing preventive maintenance requirements; following manufacturer's instructions; troubleshooting malfunctions; calling for repairs; maintaining equipment inventories; evaluating new equipment and techniques.
• Other duties as assigned.

Specialty Essential Functions

• Discharge Planning
  • Assesses, plans, implements, coordinates, monitors and evaluates options for patients, their families, caregivers, and the health care team, including providers, to promote effective care coordination outcomes.
  • Coordinates alternate levels of care based on the patient's current needs and availability of healthcare resources.
  • Creatively resolves complicated disposition issues, utilizing community resources with the integration of the patient's available benefits to achieve a positive outcome.
  • Provides information for appropriate referrals to patients and their families, and provides counseling, if needed, on a limited basis.
  • Maintains patient rights by adhering to HIPAA, Freedom of Choice, Rights of Reconsideration, QIO, and other regulatory agency requirements.
  • Facilitates the flow of care to expedite appropriate discharge and prevent readmission.
  • Involves patients and families in goal setting and evaluation health care system.
  • Ensures safe and effective transitions of care across settings for patients.
• Case Manager works in collaboration with the Denial Management Specialist:
  • Facilitates appeals/grievances for concurrent and retrospective appeals.
  • Assists with maintaining databases that reflect the appeal/grievance component of the utilization process.
  • Consults with Denial Management Specialist, department Manager and Physician Advisor or designee to resolve issues regarding adverse determinations and denials.
  • Assists the Denial Management Specialist in designated facets for the appeal/grievance process, including medical record review for medical necessity, conferring with Physician Advisor or designee, formulating correspondence, and maintaining accurate files.
  • Provides timely correspondence to meet requirements of all payors, as it relates to the appeal process.
  • Collaborates with Patient Accounting Department and other ancillary departments for resolution of payor reimbursement issues in a timely manner.
  • Responsible for data collection related to status of denials/delays.
• Case Manager works in collaboration with Utilization Review
  • Completes initial utilization review for medical necessity for an assigned patient population.
  • Initiates assessment within 24 hours of admission or next business day.
  • Applies Intergual criteria for severity of illness/intensity of service indicators. Makes referral to PA/VPMA or designee for second level review in cases not meeting initial medical necessity criteria screens.
  • Recognizes and progresses the plan of care when an alternative level of care is appropriate.
  • Conducts continued stay reviews by monitoring patient’s response to treatment and resource utilization.
  • Collaborates with Attending Physician and healthcare team to facilitate the progression of the plan of care.
  • Completes initial and continued stay reviews in a timely manner, in accordance with various payor contracts and guidelines.
  • Cognizant of payor requirements for all patients in assigned caseload. Responsible for understanding and communicating plan benefit limits/availability to patient or their representative in management of case as necessary.
  • Responsible for accurate and timely documentation in recognized data bases to support Clinical Resource Management components for each patient in assigned caseload. Identifies, track and trends Avoidable/Delay Days in Midas System.
  • Monitors length of stay and ancillary resources use on assigned patient caseload. 

Required Qualifications 

• Graduate of an accredited Nursing Program.
• Three (3) years of clinical experience in healthcare or recent case management experience.
• Strong leadership ability, good organizational skills, independent and critical thinking skills, sound judgment, and knowledge of legal aspects and liability of nursing practice.
• Strong ability to communicate complex and/or controversial topics and concepts to a wide and diverse audience.
• Proficient documentation skills.
• Knowledge of Payor/Insurance benefits.
• Functional skills on PC and related software (Microsoft Office).
• Excellent negotiation skills. Strong analytical, data management, and PC skills.
• Current working knowledge of utilization management, case management, and discharge planning.
• Current working knowledge of community resources, post-acute services.

Preferred Qualifications 

• Recent Acute Care experience.
• Bachelor’s Degree in Nursing.

License, Certification & Clearances

• Current licensure to practice as a Registered Nurse in the State of Pennsylvania

• Act 33 with renewal
• Act 34 with renewal
• Act 73 FBI Clearance with renewal
• Case Management Certification preferred. 

Supervisory Responsibilities

• This position has no direct supervisory responsibilities, but does serve as a coach and mentor for other positions in the department.

Position Type/Expected Hours of Work

• Incumbent will be scheduled based on operational need (rotate shifts, standby, on-call, etc.).
• Travel may be expected locally between Excela Health locations.

LEAN

• Actively promotes a Lean work culture by performing team member duties to encourage consistent use of LEAN principles and processes, including continually seeking work process improvements. Recognizes the necessity of taking ownership of one’s own motivation, morale, performance and professional development. Strives for behavior consistent with being committed to Excela’s missions, vision and values.

AAP/EEO 

• Excela Health is an Equal Opportunity Employer. It is the policy of Excela Health to prohibit discrimination of any type and to afford equal employment opportunities to employees and applicants, without regard to race, color, religion, sex, national origin, age, marital status, non-job related disability, veteran status, or genetic information, or any other protected class. Excela Health will conform to the spirit as well as the letter of all applicable laws and regulations.
• Ability to perform the Essential Functions listed on the Physical Conditions and ability to perform the Essential Functions on the Working Condition chart below.

Work Environment

Effective March 2020 or during pandemic: goggles, face shield and mask are required according to CDC guidelines

Physical Demands

When lift requirement is in excess of 50#, lift assistance (2 person) and/or transfer device is required.