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Case Manager - Medical

REPORTS TO: Director of Care Management
SUPERVISES: None

JOB SUMMARY: The Case Manager position is a full time position that is responsible for conducting case management and any related utilization management and quality activities in accordance with Health Integrated policies and procedures. The position responsibilities include the management of assigned cases to ensure costs are contained and quality of care is maintained as the patient accesses care and services in the continuum of care.

SCOPE OF PRACTICE: Case Management, according to the Case Management Society of America, is defined as; “a collaborative process of assessment, planning, facilitation for options and services to meet an individual's health needs through communicating available resources to promote quality cost-effective outcomes.” This service is recognized as an organized process designed to ensure the medical necessity and cost effectiveness of a proposed service. Case Management is designated to promote optimal recovery and rehabilitation by professional involvement in the rehabilitation process.

MINIMUM QUALIFICATIONS:

Education: A bachelors (or higher) degree in a health-related field and licensure as a health professional (where such licensure is available), or;
Certification as a case manager, or;
RN licensure and three (3) years clinical practice experience and
Practice case management within the scope of their licensure (based on the standards of the discipline)

Experience:

Two - three years clinical experience in case management or acute hospital discharge planning preferred;
Three years clinical or critical care experience in medical/surgical practices or behavioral health practices; or
Three years of experience in applying healthcare criteria or a behavioral health set of criteria
Call center knowledge desirable

Knowledge/skills:

Strong communication, documentation, clinical and critical thinking skills and problem solving skills are essential;
Working knowledge of community resources and alternate funding resources;
Working knowledge of details/resources that are required to individualize a case, contain costs and maintain quality of care for persons with a catastrophic or high-cost illness or injury;
Strong problem-solving, decision-making, and negotiating skills are essential;
Strong skills in dealing with difficult and challenging personalities and situations are essential;
Excellent typing and computer skills, and ability to collect data as assigned for reporting purposes;
Ability to communicate and work with a multidisciplinary team (internal and external) to facilitate day-to-day workflow; and,
Ability to recognize and communicate any concerns or issues to CM Supervisor in a professional and timely manner.

ACCOUNTABILITIES:

Job Performance/Responsibilities:

General Duties

Adheres to CM program goals and objectives in health care cost containment while maintaining a high quality of health care delivery system to meet the patient's individualized health care needs through adherence to program policies and procedures;
Must become knowledgeable of URAC requirements for Case Managers for CM accreditation;
Performs telephonic case management activities, communicating with the multidisciplinary team in the timeframes required to meet program goals and objectives;
Performs telephonic and utilization management reviews in accordance to health purchaser contractual requirements, using InterQual criteria and HI Behavioral Criteria Set;
Assigns Length of Stay/Day Limits per LOS standards for the level of care requested, referring questionable cases to the Medical Director and/or health purchaser client for the final review and coverage determination;
Communicates all UM coverage determinations in accordance to health purchaser contractual requirements and/or any state/federal regulatory requirements;
Collects pertinent clinical information (including specific claims data when available), documenting findings using the HI case management information system program/hard copy charting;
Summarizes and documents pertinent verbal discussions with the patient/patient's legally appointed representative, family, practitioner, other health care provider or the health purchaser staff, and/or any case conferences;
Promotes alternative care and funding programs and researches available options to maximize health benefits and/or replace limited or excluded benefits;
Promotes appropriateness of resources/placement when alternative level of care is required;
Communicates directly with the patient/patient’s legally appointed representative, practitioner, other health care providers and team members when appropriate to gather all clinical information to determine the medical necessity of requested or needed health care services;
Serves as a patient advocate when deemed applicable or as requested by the patient/patient's legally appointed representative; and,
Initiates patient assessment.
Assess the client's strengths, problems, prognosis, functional status, goals and need for specific services/resources, to establish short-term and long-term goals.
Develops a plan, when indicated, through interdisciplinary collaboration which identifies options and goals.
Identifies, procures and coordinates services and resources necessary to implement the individual's plan.
Provides ongoing evaluation of the individual's progress, effectiveness of the rehabilitation plan, as well as, the efficacy and appropriateness of the services provided.
Advocates on behalf of the individual to assure quality of care and attainment of appropriate goals.
Promotes individual's self-advocacy skills to achieve maximum self-sufficiency.
Communicates directly with the designated Medical Director or Physician Advisor or the Chief Medical Officer regarding all care/costs that:

Are questionable;
Do not meet criteria;
Do not appear to meet medical necessity guidelines;
Are experimental/investigational;
Are beyond the dollar amount or scope allowed for the individual case manager;
Are requested/required out-of-network;
Are required over a prolonged period of time and an extended authorization for care is deemed appropriate for meeting a patient's individualized health care needs.

Refers cases to HI legal and/or health purchaser’s legal staff where there is a threat of litigation and/or those patient's specified by the legal department for immediate referral;
Recommends, coordinates or educates regarding alternate care options for patients, families, practitioners, providers or other members of the multidisciplinary health care team;
Identifies any teaching required by the multidisciplinary health care team before the care/alternative level of care can be implemented;
Identifies, in collaboration with the patient/patient's legally appointed representative, practitioners, other health care providers, health purchaser, the multidisciplinary team members and/or the HI Chief Medical Officer/Medical Director, the resources that will be required to meet/manage the patient's level of care/acuity of care requirements;
Identifies and communicates to supervisor/director, all hospital ancillary providers, physician providers and physician offices, any concerns related to patient safety.;
Develops, monitors and updates an individualized patient specific CM Plan in collaboration with the patient/patient's legally appointed representative, practitioners, and the multidisciplinary team members;
Sets realistic, short and long-term goals for the patient as the CM Plan is developed and/or revised;
Monitors the CM Plan at regular time intervals and/or at the time frequency dictated by the patient's level of acuity, making recommendations for change when opportunities are identified and/or as the patient's illness/health care needs improve or deteriorate;
Negotiates discounts or reduced charges when an out-of-network provider is required to manage the level of care/acuity of the case at hand and/or in accordance to health purchaser contractual requirements;
Maintains an active role in assuring continuity of care for patients through early identification and appropriate discharge planning by close and frequent collaboration with the hospital discharge planning/social worker staff;
Closes and/or transitions stabilized cases after collaboration with CM Supervisor and/or Chief Medical Officer/Medical Director
Readily available to non-clinical staff to answer questions and ensure that non-clinical staff is performing within the scope of the non-clinical role

Customer Services-Internal

Creates and supports a positive and supportive working environment;
Identifies and resolves potential personnel/peer problems and issues proactively;
Communicates to CM Supervisor and/or Director UM/CM all problems, issues and/or concerns as they arise;
Maintains a courteous and professional attitude when working with all HI staff members and the management team;
Actively participates in any CM team meetings;
Actively participates in any UM and CM committee meetings as assigned; and,
Serves as a positive role model for peers.

Customer Service-External

Works, communicates and collaborates in harmony and in a courteous and professional manner with patients, practitioners/providers, health purchaser clients and their staff, and the HI multidisciplinary team;
Timely processes and communicates, identifies and resolves all issues and concerns related to the day-to-day case management activities as assigned/designated;

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