TORRANCE MEMORIAL MEDICAL CENTER. Vice President

Transcription

1 JOB DESCRIPTION TORRANCE MEMORIAL MEDICAL CENTER Department: Job Title: Approvals: NURSE I Director Vice President POSITION PURPOSE: Under supportive supervision, the level 1 RN Case Manager position is to support the physician and interdisciplinary team in the provision of patient care, with the underlying objective of enhancing the quality of clinical outcomes and patient satisfaction while managing the cost of care and providing timely and accurate information to payers. The role integrates and coordinates utilization management, care facilitation, Home Health and Hospice and discharge planning functions. The level 1 RN Case Manager is accountable for a designated patient caseload and plans effectively in order to meet patient needs, manage the length of stay, and promote efficient utilization of resources. Specific functions within this role include facilitation of and payer authorization processes; facilitation of the collaborative management of patient care across the continuum, intervening as necessary to remove barriers to timely and efficient care delivery and reimbursement; application of process improvement methodologies in evaluating outcomes of care; support and coaching of clinical documentation efforts and serving as a clinical resource for coders; ensuring that documentation accurately reflects severity of illness (SI) and intensity of service (IS); coordinating communication with physicians. She/he applies MCG evidenced based clinical guidelines to determine medical necessity and level of care. REPORTING RELATIONSHIPS: This position reports to the Manager of Case Management. Accountability for the practice of nursing lies with the Senior Vice President of Patient Care Services. PRIMARY DUTIES AND RESPONSIBILITIES: The level I Case Manager RN uses effective problem solving in her daily performance as a team member. She/he functions independently with immediate support available to consistently demonstrate the following: 1. Performs chart reviews and quality assessments on all patients using knowledge of MCG guidelines. Provides accurate clinical documentation. Page 1 of 5 NURSE I 2410 JD

2 2. Monitors the activity of observation cases to see that the patient is appropriately discharged in a timely manner. Works with Physician Advisors to screen for possible changes in status to inpatient services. Initiates and follows up with the ED or in hospital protocol for secondary review process. 3. Initiates Medi-Cal Treatment Authorization Request (TAR) at time of admission or as soon as possible thereafter. Documents daily using SI and IS criteria. 4. Works with physician advisors and appropriate hospital personnel regarding criteria for Utilization Management. 5. Ensures delivery of Important Message from Medicare (IMM) to all inpatient Medicare beneficiaries of their hospital discharge appeal rights and notification of admission under observation (OBS) status by educating and providing informational brochure. Documents appropriately on electronic medical record, IMM/OBS form. 6. Provides documentation for denial letter and delivers denial letters to patients as directed by Utilization Management (UM) Committee. Utilizes the Quality Improvement Organization (QIO) Appeal Tracking form for Medicare patients. 7. Researches and prepares appeal for denial of claims. 8. Identifies inappropriate bed utilization and quality of care problems and refers them to UM Committee. 9. Refers appropriate cases to UM Committee. For example, Risk Management issues 10. Utilizes Readmission Risk Assessment form as readmission prevention assessment tool. Makes appropriate referrals for the Care Coordination Center. Supports the Torrance Memorial Health Systems Care Transitions Program. Provides post-acute care options to patients and family ensuring their rights to select any preferred provider. 11. Gives initial review and updates insurance providers to obtain certification of days and payer authorization process. 12. Contacts insurance providers, as required, to ensure reimbursement and verifies post hospital service coverage. Obtains authorization for post-acute care as needed. Interacts with other departments, e.g., Business Office and Patient Access. 13. Monitors patients without insurance and refers them to the Medi-Cal worker when appropriate. Places patient in the Medical Alert Center (MAC) notification system when appropriate. 14. Facilitation of the collaborative management of patient care across the continuum as necessary to remove barriers to timely and efficient care delivery and reimbursement. Page 2 of 5 NURSE I 2410 JD

3 15. Manages all aspects of discharge planning for assigned patients as follows: Meets directly with patient/family to assess needs and develop an individualized continuing care plan in collaboration with the physician. Collaborates and communicates with Interdisciplinary Care team in all phases of discharge planning process, including initial patient assessment, planning, implementation, interdisciplinary collaboration, teaching, and ongoing evaluation. Ensures/maintains plan consensus from patient/family, physician, and payer. Refers appropriate cases for social work intervention based on department criteria. Collaborates/communicates with external case managers. Initiates referrals for home health care, hospice, and medical equipment and supplies. Documents relevant discharge planning information on the interdisciplinary Discharge Planning Assessment form as appropriate. Facilitates transfer to other facilities. 16. Proactively identifies and resolves delays and obstacles to discharge. Intervenes at various points in the patient s stay to assure that the objectives/goals of the hospitalization are achieved in collaboration with the Interdisciplinary Care team. For example, timely results of CXR, MRI, labs, etc. to prevent delay in discharge. 17. Provides patient/family information about community resources. Provides information to patients/families relating to patient rights and responsibilities. Utilizes Community agencies and resources as needed. 18. Anticipates and assesses needs of patients prior to discharge order and independently of physician s direction so that timely provision of post hospital care needs may be met. 19. Collaborates with the Interdisciplinary Care team to develop a hospital or discharge plan of care agreeable to the patient and family. For example, nursing, rehabilitation and other ancillary departments. 20. Collaborates with the Interdisciplinary Care team to move the patient along the continuum intervening as necessary to remove barriers for timely efficient care delivery. 21. Attends Interdisciplinary Care conferences/ team meetings where appropriate to discuss patient s home situation, level of independence and activities of daily living, home management and environment, and anticipated discharge needs for continuum of care. 22. Maintains a working knowledge of current Medicare requirements for acute hospitalization, home care, skilled nursing facility (SNF), extended care facility (ECF), and hospice reimbursement. Maintains a working knowledge of the changing Medi-Cal regulations and other insurance (HMO, PPO) carrier regulations. 23. Complies with all applicable laws and regulations. Page 3 of 5 NURSE I 2410 JD

4 24. Documents in the CM Discharge Planning Assessment form regarding patient s home situation and support systems, level of activity, equipment already in the home, and discharge plan including patient/payer preference of agency to ensure communication with the physician and other hospital staff. Also documents appropriately on electronic medical record. 25. Coordinates orders of all physicians involved in discharge arrangements and care. Follows medical recommendations and provides service planned to restore patients to optimal social and health adjustment. 26. Interviews patients, family members and/or caregivers, interface with responsible physicians, and reviews medical records. Determines appropriate post-hospitalization facilities (home versus supervised living situations, board and care facility, extended care facility, or rehabilitation facility), durable medical equipment, post-discharge nursing and/or therapist interventions, social service involvement, and need for assistance with activities of daily living. 27. Follows up on the CM Discharge Planning Initial/Ongoing Assessment patient care plan to determine if any changes are necessary every 3-5 days. 28. Contacts and assesses facilities and agencies for referrals and determination of their level of care. Utilizes Ensocare/Care Finder Pro to place multiple referrals to local service providers, for example, SNF placement or durable medical equipment request. Utilizes Transitional Care unit (TCU) Screening Record form to make appropriate referrals for SNF and/or short-term rehabilitation needs. 29. Ensures resources and supplies are available at time of the patient s discharge. 30. Utilizes conflict resolution skills as necessary to ensure timely resolution of issues. Develops and maintains cooperative relationships with hospital personnel, physicians, suppliers and insurance case managers. 31. Educates hospital staff, physicians, and the community regarding home care, SNF, ECF, Board and Care, Assisted Living, Hospice Services and Appropriate documentation. 32. Ensures/arranges transportation for the patient at discharge. 33. Prepares and keeps current documentation for each assigned patient. 34. Performs other duties as assigned. 35. Demonstrates his/her role in department specific patient safety. For example, hand hygiene, infection control practices, fall risk precautions. 36. Reports errors, knowing that Torrance Memorial engages in a positive environment for the correction of errors (non-punitive). Page 4 of 5 NURSE I 2410 JD

5 37. Embraces and demonstrates a commitment to TMMC values of Service, Excellence, Knowledge and Stability by actively participating and adhering to the values on a daily basis. 38. Participates in hospital performance improvement activities when assigned. 39. Ensures that privacy and confidentiality rules are followed in accordance with Torrance Memorial Medical Center, State, Federal, and HIPAA regulations. 40. Demonstrates/role models behaviors that are consistent with the Torrance Memorial Medical Center values of Service, Excellence, Knowledge, Stability and Community. 41. Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department based goals which contribute to the success of the organization; serves as a preceptor, mentor and resource to less experienced staff. 42. Communicates information to Supervisor regarding competencies and learning needs of Case Management and support personnel. INTERPERSONAL RELATIONSHIPS: Interacts with hospital personnel, physicians, nursing staff, patients and their families, and caregivers, outside agencies, third party payers, independent contractors, and facilities throughout the community. Adherer s to the standards of behavior. WORK ENVIRONMENT/HAZARDS: Fast-paced environment with many distractions. Extended periods of time sitting, standing and walking. Works in patient care areas and office setting. Works throughout the community. Rapidly changing priorities. Exposed to acutely ill patients. POSITION QUALIFICATIONS: Current California RN license. Two years recent clinical experience. Current BCLS certification. Bachelor or recent (within 2 years) ED or ICU experience. ********************************** Initial Effective Date: 4/2014 Revised Effective Date(s): Reviewed Date(s): Revised Date(s): Page 5 of 5 NURSE I 2410 JD