Case Manager- Hamilton, NJReq #:0000137934

　　Category:Nurse Case Manager

　　Status:Full-Time

　　Shift:Day

　　Facility:RWJ Hamilton

　　Department:Case Management

　　Location:

　　RWJUH Hamilton Hospital, One Hamilton Health Place, Hamilton, NJ 08619

　　Job Summary

　　Promotes high quality patient care and cost effective utilization of hospital resources through concurrent and retrospective evaluation of patient care through the medical record. Performs concurrent review of Managed Care to obtain payment for services rendered. Monitors Medicare patients for appropriate utilization. Formulates discharge plans for patients for continuation of care needs. Reports to Director of Patient Management.

　　Essential Job Functions

　　Conferences with Physician advisor and attending physician to discuss plan of care. Coordinates with ancillary departments to mobilize resources for completion of timely inpatient care.

　　Independently determines level of care and communicates through Notice of Non-coverage letters when required.

　　Utilizes guidelines with Managed Care. Documents appropriate guidelines used in determination. Documents information related to case for consideration when appealing. Reports level of care changes to director.

　　Obtains authorization and utilizes ambulance transport when needed and informs families of Medicare guideline requirements.

　　Completes concurrent and retrospective review according to departmental UR plan inlcuding Interqual, Milliman, and/or Medicare guidelines.

　　Communicates with payors regarding assessments, utilization of resources, outcomes, and anticipated length of stay.

　　Reviews each case for appropriateness of admission or assignment to observation status. Initiates communication and referral activity to maintain status criteria.

　　Completes reviews on assigned patients daily and enters information into canopy using Interqual, Milliman, and/or Medicare guidelines.

　　Monitors appropriates of test/procedures, consultation, treatment plans and resource utilization. Discuss findings and refers appropriately.

　　Maintains and assures adherence to clinical paths, tools and protocols through collaboration with the interdisciplinary team to reduce LOS and resource utilization.

　　Leads the Interdisciplinary rounds in collaboration of the team and plays an active role in providing for the continuum of care.

　　Coordinates with ancillary departments to mobilize resources for completion of timely inpatient care.

　　Facilitates patient movement to appropriate (acuity) level of care through collaboration with patient/family, interdisciplinary team, and payors.

　　Coordinates and documents discharge planning needs within the department timeline including choice with regards to Medicare.

　　Assists families in understanding discharge planning options and obtains authorization for services when needed.

　　Proactively work with patients, families, physicians and the interdisciplinary team to prepare the patient for a safe discharge post hospitalization.

　　Identifies, documents and reports variances such as risk for readmission, quality, safety and infection control issues.

　　Reports and works actively to address quality of care issues such as delays and inappropriate utilization in treatment, appropriately escalating times as needed.

　　Demonstrates fiscal responsibility related to patient needs, resource utilization, payor requirements and organizational goals.

　　Maintains awareness of department staffing needs and demonstrates flexibility and willingness to assist coworkers in other areas as census/staffing demands.

　　Work hours reflect productivity, commitment and flexibility toward needs of department and hospital goals.

　　Demonstrates motivation and initiative in role performance; proactively address identified issues and resolves problems.

　　Contributes to departmental/organizational project and performance improvement activities

　　Participates in activities that increase professional/departmental knowledge and skills such as attendance in lectures, conferences, in-service programs and meetings.

　　Monitors Epic work queues and addresses outstanding items

　　Job Qualifications

　　Prior case management experience

　　Diverse clinical experience in both Med/Surg and Critical Care a plus

　　3 - 5 years clinical hospital experience preferred

　　Currently licensed NJ Registered nurse

　　Case Management Certification preferred

　　Excellent verbal and written communication skills required

　　Must be able to make decisions, work independently and communicate effectively with Interdisciplinary teams, patient, families, and physician staff to formulate a safe discharge plan

　　RWJBarnabas Health is an Equal Opportunity Employer