Case Manager Senior Behavioral Health Full Time Day Shift

POSITION SUMMARY

• The goal of hospital Case Management is resource coordination along a continuum to help patients to achieve optimal health, access to care and appropriate utilization of resources
• Case managers work collaboratively with patients, nurses, physicians and other practitioners, caregivers and community resources and agencies to provide cost effective care that reflects a patient’s preferences and values
• Healthcare is a right, and patients have choices
• Our services should reflect that concept

Responsibilities of the floor case manager are as follows: 

• Manage entire census for UR/DC planning for the floor you are assigned
• Review every status order and ensure accuracy. Handle inappropriate status orders per protocol
• Review all observation cases minimally twice daily
• Review all new admissions and provide UR to insurance companies per regulations
• Perform and submit continued stay reviews daily
• Perform continued stay reviews every 48 hours for payor not requiring submission
• Organize and plan discharges for the day
• Daily rounding with treatment team
• Perform high risk assessment on all patients when admitted
• Perform discharge screen/assessment on day one. Reassess every 48 hours
• Have patients sign choice letters, when needs are identified
• Make post-acute care referrals as need is identified
• Issue Important Message from Medicare letters initially if needed, and within 48hours prior to discharge
• Issue MOON to observation patients
• Issue HINNs as needed
• Complete Code 44’s as necessary
• Identify and review 30 day readmits. Collaborate with treatment team to prevent further readmissions
• Understand DRG/GMLOS to appropriately discharge plan in collaboration with physicians
• Avoidable days management
• Responsible for knowing and practicing the Utilization Management Plan

The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements that may be inherent in the position.

ORGANIZATIONAL RELATIONSHIPS 

• A direct reporting relationship is established to the Case Management department director. Interacts with medical center personnel, patients, and providers on a daily basis.

GENERAL POSITION INFORMATION

• Required to maintain a general knowledge of regulations and insurance provider requirements and remain up to date as programs change
• Responsible for interpreting applicable payor, QIO, and CMS requirements
• Expected to participate in continuing education programs as required by the Medical Center
• Accepts personal responsibility for other educational activities to enhance job-related skills and abilities
• Must be self-directed and able to make effective decisions consistent with Medical Center policies and demonstrate professional, mature judgment
• Superior communication skills that include the Language of Caring skills are essential for the position
• Demonstrates a commitment to St. Joseph Regional Medical Center’s Mission, Philosophy, and Values

EDUCATION AND EXPERIENCE REQUIRED

• Licensed Practical Nurse (LPN) -OR- associate degree in nursing (RN) OR- bachelor’s degree in social work -OR- master’s degree in social work
• Evidence or ability to develop programs to support the delivery of professional practice based on current knowledge and sound theoretical principles is required

PREFERRED

• Bachelor’s degree in Nursing or related field and an active Wisconsin State RN or LPN License
• Three years’ experience in utilization/case management or acute care nursing is also preferred
• Utilization and/or case management certifications preferred

WORKING CONDITIONS

• Primarily sedentary, general office environment with daily, frequent use of the telephone and computer requiring near visual acuity
• Walks about the Medical Center
• Attends meetings
• Lifting of 8-10 pounds if moving or lifting files
• Stooping and bending required for retrieval of files