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The Case Manager is responsible for compliance with CMS Conditions of Participation regarding Utilization Review and Discharge Planning including implementation and annual review of the Utilization Management Plan and assisting with the coordination of the Utilization Management Committee. The Case Manager is also responsible for ensuring compliance with provisions of care regarding discharge planning and patient needs for care, treatment, and services after discharge or transfer are met. The Case Manager follows the hospital's Case Management/Utilization Program that integrates the functions of utilization review, discharge planning, and resource management into a singular effort to ensure, based on patient assessment, care is provided in the most appropriate setting utilizing medically indicated resources. The hospital’s case management model outlines a collaborative practice to improve quality through coordination of care impacting length of stay, minimizing cost, and ensuring optimum outcomes.
Promote the mission, vision, and values of the organization
Facilitate team meetings that foster interdepartmental collaboration with the patient and their family as deemed necessary, this includes multidisciplinary meetings and Utilization Review/Case Management meetings. Provides input in such meetings regarding utilization management and discharge planning.
Responsible for evaluating and screening potential admissions to the facility when appropriate.
Knowledgeable of criteria for Medicare, Medicaid, HMO and private insurance coverage.
Communicate daily with admissions personnel regarding admissions and discharges to various units.
Initiate ongoing communication with the resident and resident’s family to assess discharge needs.
Communicate with physicians to ascertain their plans for a timely discharge.
Document discharge planning as an ongoing review.
Knowledgeable of resident’s financial status, diagnosis and discharge needs.
Responsible for home care needs being met by the time of discharge, with a goal of arrangements completed 24 hours prior to discharge when date of discharge is known.
Cooperate with insurance companies, based on information received.
Manage and collaborate with the healthcare team and complete documentation as necessary.
Ensures that a quality of care is maintained or surpassed by collecting quality indicators and variance data and reporting the data to the appropriate department; reports and identifies data that indicates potential areas for improvement of care and services provided within the system.
Assist as needed with obtaining referrals, prior authorization for Home Health Care, DME, SNF, acute rehab and appointments.
Educates physicians and staff regarding appropriate level of care/utilization issues.
Develop and implement methods, policies and procedures to improve the departments’ efficiency and overall effectiveness.
Oversight and evaluation of the discharge planner/ utilization review nurse.
Perform and oversee needs analysis and planning. Work with executive leadership to ensure targets are met for the annual operating plan/financial management.
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