Clinical Resource Manager Case Manager

SUMMARY:

 Provides hospital case management/utilization review and discharge planning collaboratively determining level of care needs beyond acute care, providing decision support to patients/families and physicians, managing patient and family expectations, and ensuring a smooth transition to the next level of care and services.  Coordinates the integration of social services into patient care as appropriate. Coordinates the hospital activities concerned with case management/utilization review and discharge planning. Adheres to departmental goals, objectives, standards of practice, and policies and procedures. Ensures quality patient care and adheres to regulatory compliance. Provides concurrent assistance and support to physicians and other clinical members of the health care team in coordinating the delivery of services for a select group of patients.  To help achieve quality clinical and cost outcomes, incorporates real-time contacts with physicians, nursing, and ancillary care givers to establish specific treatment, cost, and transition targets and to facilitate transition planning.  

REQUIREMENTS:  

• Colleague must have an RN license, as defined by their primary work state (Idaho or Oregon)  

• IDAHO ONLY: If a nurse moves to Idaho from another compact state, they must apply for licensure by endorsement and update their primary state of residence to Idaho within 60 days of being hired. 

• All colleagues must provide licensure or proof of application for secondary state within 90 days of hire. 

• BSN required. A master's degree is preferred. 

• A minimum of 2 years of varied hospital clinical experience is required.   

• Experience in case management, home health, and/or the insurance industry preferred. 

WHAT YOU WILL DO:

• Knows, understands, incorporates, and demonstrates the Organization's Mission, Vision, and Values in behaviors, practices, and decisions. 

• Demonstrates knowledge and skills to competently care for all assigned age groups (Neonate, Child, Adolescent, Adult, Geriatric as applicable). 

• Revenue Management: ensures the accuracy of documenting services and supplies provided to the patients. 

• Coordinates the integration of social services/case management functions into patient care, discharge, and home planning process with other hospital departments, external service organizations, agencies and healthcare facilities. 

• Completes a screening/assessment of physician assigned cases to determine medical necessity/status determinations and transition needs. Reassesses, monitors, and modifies transition needs as appropriate. 

• Conducts concurrent medical record review using established medical necessity criteria to determine correct level of care for acute patients. Assists physicians with completing transfer and discharge orders. Maintains knowledge of federal, state, and private agency review requirements and regulations. 

• Provides education to all health care team members including physicians regarding requirements to meet regulatory standards.  

• Promotes effective and efficient utilization of clinical resources from admission to discharge. 

• Initiates and presents "denial letters" as appropriate. Completes PASRRs for admission to skilled nursing facilities. Delivers Condition Code 44 letters to patients and educates them on Medicare benefits. 

• Researches and locates resources for patients for example: assistance in competing medication applications for financial assistance through pharmaceutical companies, works closely with our Patient Financial Advocates in the Medicaid pending process, and works closely with outside facilities to obtain equipment in situations when patients have limited funding available to them. 

• Communicates with physicians at regular intervals throughout hospitalization and develops an effective working relationship. Assists physicians to maintain appropriate cost, cases, and desired patient outcomes. 

• Introduces self to patient and family and explains clinical resource manager role and the process for patient and family to contact clinical resource manager. 

• Serves as a patient advocate. Enhances a collaborative relationship to maximize the patient's and family's ability to make informed decisions. 

• Participates in multidisciplinary patient care rounds and/or conferences as appropriate to review treatment goals, optimize resource utilization, provides family education and identification of post-hospital needs. 

• Utilizes physician advisor referral as appropriate.  

• Adheres to department established process in reviewing 30 day re-admissions. 

• Follows established patient choice policy. 

• Documents assessment of primary and back up plans along with communications to patient, family and care team. 

• Documents interventions taken to meet the needs of their individual patients in Power Chart. 

• Actively participates in department staff meetings and department sub teams. 

• Ensures discharge planning compliance with Medicare Conditions of Participation/regulations and Joint Commission standards.

Colleagues of Saint Alphonsus Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout SAHS and Trinity Health.

Visit www.saintalphonsus.org/careers to learn more about the benefits, culture and career development opportunities available to you at Saint Alphonsus Health System.

Saint Alphonsus and Trinity Health are committed to promoting diversity in its workforce and to providing an inclusive work environment where everyone is treated with fairness, dignity and respect. We are committed to recruit and retain a diverse staff reflective of the communities we serve. Saint Alphonsus and Trinity Health are equal opportunity employers and prohibit discrimination against any individual with regard to race, color, religion, gender, marital status, national origin, age, disability, sexual orientation, or any other characteristic protected by law.