The purpose of this position is to be responsible for assisting the implementation of the hospital’s Care Management Plan.
Assesses, plans, implements, monitors and evaluates options to facilitate the continuum of care.
Promotes quality care through the efficient and effective use of the Hospital’s resources by exerting special efforts in reviewing medical necessity of admission, length of stay, promptness of service, use of consultations and implementation of effective discharge planning.
Identifies and isolates problematic Diagnosis Related Groups (DRG’s), other diagnosis or procedures and suggest methods for improvement.
Collaborates with payors and review organizations to ensure proper utilization of patient care resources.
Implements guidelines to ensure completeness, validity and reliability of patient discharge information.
Reviews patient records according to payor contractual agreements or as needed.
Investigates, identifies and defines problems relating to the quality of patient care and reports the information gathered to committees, credentialing, and regulatory agencies such as Joint Commission, the Department of Health, etc.
Serves as an education and communications resource regarding utilization review, level of care and case mix reimbursement.
Provides information/documentation on changes of outside agencies’ policies and procedures to Hospital staff and patients to maximize reimbursement and quality of care in the Hospital.
Prepares/compiles patient and Hospital data requirements for periodic reports, such as utilization screens, and clinical pathway systems i.e. Interqual, Milliman etc.
Attends internal/external meetings for committees responsible for utilization management and performance improvement activities.
Documents the status and condition of patients when they are transferred to other units and provides report to the Care Manager covering the unit.
Performs specific studies on patients’ length of stay, re-admission, one-day stays, etc. and reports to outside agencies for statistical purposes.
Maintains current literature on preadmission screening criteria and policies and procedures of insurance carriers.
Generates and analyzes data on the trends and utilization of Hospital resources and prepares reports for management and designated Hospital committees.
Performs simple discharge planning tasks, such as: expediting labs and consulting radiology studies, etc.
In the absence of other care managers, provides coverage to other units
Troubleshoots and resolves problems/issues as they relate to the utilization of resources.
Participates in discharge planning rounds by meeting with patients and conferencing with interdisciplinary teams.
Identifies the absence of appropriate documentation in the progress notes.
When assigned to the Emergency Department, takes calls for Direct Admissions and provides recommendations to the physicians about the preferred patient status based on Interqual criteria.
Assumes other duties and responsibilities that are related and appropriate to the position and area. The above responsibilities are a general description of the level and nature of the work assigned to this classification and are not to be considered as all-inclusive.
Must be able to stand, walk, sit, lift (12-25lbs - books, files, papers), bend, pull, push, reach, handle, write, type (finger dexterity), file, speak, hear, see (depth perception), calculate, compare, edit, evaluate, interpret, and organize for extended periods of time.
- Bachelor of Science degree in Nursing or a related field.
- In lieu of a Bachelor of Science degree, graduate of a professional nursing program with a minimum of two (2) years of case management experience in a hospital setting.
- Current District of Columbia license to practice as a Registered Nurse or eligible for endorsement.