University of Maryand Midtown Campus is currently seeking a Case Manager to join our Case Management Team.
We are looking for a Licences RN, NP, or PA for this position
Under the direction and supervision of the Director of Care Management, the Care Manager, is a part of an interdisciplinary team including patients, nurses, social workers, physicians, other practitioners, caregivers and the community. The goals of Care Manager include the achievement of optimal health for the patient, access to care and appropriate utilization of resources, balanced with the patient’s right to self-determination. The Care Manager with respect to payer requirements will ensure timely notification and communication of pertinent clinical data to support admission, clinical condition, continued stay and authorization of post-acute services. The Care Manager will assume other duties as delegated by Director.
Duties and Responsibilities:
- For all patients requiring active case management services, the care manager is expected to ensure and provide education relevant to the effective progression of care, appropriate level of care and safe patient transition.
- Conducts quality monitoring activities according to UMMC Midtown policies. Reports quality/risk issues through channels.
- The Care Manager will screen all patients (using the Risk Assessment Tool in MIDAS) for clinical, psychosocial, financial and operational factors that may affect the progression of care and through the use of identification criteria stratify patients at risk/barriers/ strengths or in need of case management services.
- Case management will utilize a validated system/defined methodology for tracking avoidable delays/days and use this information to identify and communicate opportunities for improvement. Case management will participate in the development of performance improvement activities relevant to identified opportunities
- The Care Manager will identify and address avoidable delay practice patterns that may require modification to support cost-effective care. Uses escalation process as needed
- Performs and documents appropriate admission and continued stay reviews using Intensity of Service (IS) and Severity of Illness (SI) criteria in accordance with current InterQual/Milliman Care Guidelines criteria on assigned patients.
- Case management will have a defined method to ensure the patient is in the appropriate “status” and level of care for the patient’s clinical condition. The process must include a method for secondary physician review when warranted.
- Assists UMMC Midtown achieve current denial rate goal. Denials received on assigned cases will be evaluated on the required interaction that would have been necessary to avoid the denial.
- Case management will utilize a validated system (MIDAS)/defined methodology for tracking avoidable delays/days and use this information to identify and communicate opportunities for improvement.
- Delivers to patient/family denial notifications and other required documentation per payer, ie., IM letters etc.) and provides the necessary explanations to the patient when indicated. Follows patient insurance plan guidelines whenever denials are necessary
- Case management will proactively prevent medical necessity denials by providing education to physicians, staff and patients, interfacing with payers and documenting relevant information
Care Management and Discharge Planning Functions:
- Attends Case Management Rounds. Ensures that information regarding patient clinical status, teaching care needs and discharge planning needs are facilitated. Provides feedback to nurses caring for patients which need follow up
- Confers daily with physician(s) (Attending Physicians, Consultants, House Officers), Physician Assistants and the healthcare team to make determination of the medical necessity of continued stay and or services performed.
- Arranges discharge planning referrals as ordered. Facilitates or provides necessary patient and family education as indicated during the hospital stay and post discharge. Procures health care services when needed for patients post discharge.
- Analyzes case management outcome data to identify and make recommendations within a designated service line.
- Based on the health care team's assessment and patient choice and available resources, the case manager is expected to integrate these key elements and develop and coordinate a successful transition plan. Working with the Transitional Care Team transition management planning begins at the time of care manager’s initial patient encounter (preadmission, admission, emergency department, etc.) and is reevaluated and adjusted throughout the patient’s hospital stay
Communication and Consultation Functions:
- Establishes effective communication with the health care team, patients, their families, and their significant others to ensure compliance with the plan of care and ensures UMMC Midtown customer relations policies are followed.
- Confers daily with physician(s) (Attending Physicians, Consultants, and House Officers), Physician Assistants and the healthcare team to make determination of the medical necessity of continued stay and or services performed.
- Consults with Physician Adviser/Attendings for overall direction when multifaceted clinical issues arise requiring medical expertise.
- Case management will identify available community resources/potential partners and advocate for resolution of gaps in the available resources and processes
- Documents appropriately per Care Management Policy on: Care Management Abstracts (pertinent clinical information in accordance with InterQual Criteria, MA reimbursements and other requirement by payers. BAR notes in Meditech to reflect denied days, approved days, authorization number, referrals for expedited appeals etc.
- Case management is responsible for documenting information that is not duplicative but instead is complementary and contributes to the progression of care
- Case management will provide the clinical information necessary for the appeals process of cases for which medical necessity denial has been received