RN Case Mgr – FT – Utilization Management – INTEGRIS Meadowlake – Enid Job at Integris Health in Enid, OK
RN Case Mgr
Job Code: 1318
The Case Manager is responsible for the clinical and financial outcomes for an assigned caseload of patients as appropriate. The Case Manager facilitates patient care during the hospitalization by managing, coordinating and monitoring resource utilization to achieve optimal clinical outcomes and financial goals. The Case Manager is responsible to proactively plan, coordinate and negotiate efficient patient movement throughout the continuum of care. In general, the Case Manager functions in the role of clinician, educator, researcher, manager and advocate to serve the best interests of the system and patient. Adheres to National Patient Safety Goals as appropriate based on the level of patient contact this position requires.
INTEGRIS is an Equal Opportunity/Affirmative Action Employer. All applicants will receive consideration regardless of membership in any protected status as defined by applicable state or federal law, including protected veteran or disability status.
The RN Case Manager responsibilities include, but are not limited to, the following:
- Completes a comprehensive assessment of patients clinical, psychological and financial needs utilizing all available resources.
- Recommends and coordinates timely transfers to appropriate levels of care as indicated by clinical needs and utilization criteria.
- Develops, implements, evaluates and revises, as necessary, a plan for discharge, including referrals to other health care and community organizations based on needs assessment.
- Communicates discharge care plan, and any changes in the plan to patient, family and all appropriate healthcare professionals.
- Assists physicians and hospital staff in appropriate utilization of resources through application of utilization criteria and facilitating timely discharge planning for patients.
- Coordinates services between hospital departments to facilitate timely patient discharge.
- Conducts concurrent review of patient records on admission to the hospital and as determined by the patient’s clinical condition.
- Applies utilization criteria accurately in order to determine appropriate utilization of resources.
- Notifies designated internal and external contacts of utilization issues that may affect patient care and/or reimbursement.
- Facilitates patient transfers to other health care organizations in accordance with hospital policies and all-applicable state and federal guidelines and regulations.
- Acts as a resource/advisor to physicians regarding discharge planning, medical record documentation, and all issues that may affect resource utilization and reimbursement.
- Integrates and manages established pathways, where available, to enhance clinical effectiveness and clinical resource management.
- Maintains knowledge and understanding of CMS regulations, Medicare/Medicaid, managed care and other payer regulations and benefit limits.
- Acts as a resource and provides education for patients, their family members and all health care professionals regarding HCFA regulations, Medicare, Medicaid, managed care and other payers.
- Develops and maintains knowledge and understanding of hospital and community resources, and facilitates use of most appropriate level of care to conserve patient, hospital, and payer resources.
- Identifies opportunities to reduce cost of managing patient care without impacting quality or outcomes.
- Participates in collecting and recording data for utilization and Quality Improvement reporting.
- Works collaboratively and professionally with patients, family members, and physicians, hospital staff and other individuals and agencies involved in providing patient care.
Mental Health Only:
- Leads age and developmentally appropriate patient education and recreational groups to address the emotional, physical and environmental needs of Mental Health and/or Chemically Dependent patients.
- Provides documentation daily in patients’ charts on each group facilitated.
- Facilitates discharge planning to assist patients in placement and treatment following discharge.
- Participates in the development of patient plans of care to address goals of the patient (emotional, physical, spiritual, environmental) by attending treatment team meetings
- Participates in the writing of treatment plans with other program staff and physicians on hospital approved form.
- Assists in utilization review process by contacting patients’ insurance companies to provide clinical information to authorize patient treatment.
- Serves as a patient advocate in the patients’ needs, as well as those individuals involved with patients (as relevant).
- Assists in the development and execution of marketing the program services to appropriate entities (outpatient therapists, primary care physicians, inpatient programs, etc.).
- Completes or facilitates the completion of Emergency Detention paperwork, as well as ensure its distribution and receipt by legally designated individuals.
- Provides physician ordered therapy in the areas of individual, family and marital sessions.
- Develops and facilitates age and developmentally appropriate patient psychotherapeutic groups.
- Is responsible for reviewing and noting physician orders.
- Monitors patients’ medications and provide education related to use and side effects.
- Monitors vital signs as indicated by physician orders or if deemed medically necessary.
- Assesses patients for appropriateness of admission to the program.
INTEGRIS Certified Case Management Only:
- Documents and communicates in a timely fashion patients progression throughout the continuum of care to all necessary parties via electronic, written, and verbal means.
- Apprises team members of challenges encountered throughout the continuum of care via electronic, written, and verbal means.
- Utilizing strong organizational skills, personally manage evolving calendar of commitments in the best interest of the patient and organization.
- Utilizing excellent interpersonal, collaborative, and conflict resolution skills, act in the capacity of liaison between the patient, medical provider, and the organization to achieve positive outcome.
The Case Manager reports to the Director of the Case Management Services. The Case Manager meets established deadlines, attends required inservices, maintains staff competencies and completes required documentation; collaborates and works as a team player with all disciplines; presents a professional image to all customers and patients.
Mental Health Case Managers report to the Unit Program Manager
INTEGRIS Certified Case Managers report to the Process Manager, Disability Mgmt.
Jim Thorpe Rehab Hospital: Reports to Mgr Post-Acute Care and Rehab
Required Physical Demands (Subject to Reasonable Accommodation):
Keyboarding/Dexterity: Frequently; activity exists from 1/3 to 2/3 of the time
Standing/Walking: Occasionally; activity exists up to 1/3 of the time
Strength (Lift/Carry/Push/Pull): Light (Exerting up to 20 pounds of force occasionally, or up to 10 pounds of force frequently)
Talking (Must be able to effectively communicate verbally): Yes
Color Acuity (Must be able to distinguish and identify colors): Yes
Mental Health staff must be able to assist with physical restraint of patients, utilizing the Mandt System.
This position may have additional or varied physical demand and/or respiratory fit test requirements. Please consult the Physical Demands Project SharePoint site or contact Risk Management/Employee Health for additional information.
Required to be on call as scheduled by the department.
Potential exposure to infectious diseases, potential physical danger from disturbed/irate patients and families. Emotional stress due to inability to control volume of timing of referrals and necessity to respond to a wide variety of demands and expectations from patients, families, physicians, and other health care professionals. Occupational exposure to bloodborne pathogens and other infectious materials as defined by OSHA.
All applicants will receive consideration regardless of membership in any protected status as defined by applicable state or federal law, including protected veteran or disability status.
- 5 years experience in a variety of clinical settings (e,g. home health, inpatient, physician office, clinic) required.
- Experience with managed care and payer/provider requirements preferred.
- Current licensure as a Registered Nurse (RN) in the State of Oklahoma or current multistate license from a Nurse Licensure Compact (eNLC) member state. BSN preferred.
- Excellent interpersonal communication and collaboration skills.
- Computer experience required. Windows preferred.
- Current Case Management Certification preferred, at minimum attained within one year of hire (INTEGRIS Certified Case Management only)
- Current Driver’s License issued by the state of Oklahoma.
Company: Integris Health
Company Location: Enid, OK