Registered Nurse (RN) Case Manager Clinical Documentation
Req #: 17012817
Location: San Marcos, TX
Job Category: Case Management
Organization: Central Texas Medical Center
Central Texas Medical Center
As a member of Adventist Health System, we believe that total health is achieved through a balance of physical, mental, social and spiritual well-being. With each patient’s unique circumstances in mind, our multi-disciplinary care teams provide a vast array of services, combining state-of-the-art technology with a personal commitment to creating an exceptional patient experience.
Our team members also enjoy outstanding care in the form of comprehensive health benefits, a friendly, faith-based work environment, and plenty of opportunities to learn and grow. In addition to earning the Gallup Great Workplace Award six years in a row, we have received a Mother-Friendly Worksite designation from the Texas Department of State Health Services.
Our 178-bed hospital includes a Level IV Emergency and Trauma Center, Women’s Center, Level II NICU, Sleep Improvement Center, Institute for Advanced Wound Care Healing, Rehabilitation Institute, home health and hospice care. Through our CREATION Health Institute, we also play an active role in offering free health education and community events to help support a healthy lifestyle.
PRINCIPAL DUTIES AND JOB RESPONSIBILITIES:
Utilization Review/Management Responsibilities:
- Assess for appropriate level of care and admission status utilizing nationally recognized criteria such as InterQual/Milliman.
- Promotes appropriate documentation which will accurately support the severity of illness and intensity of service.
- When documentation is not reflective of the severity of illness and intensity of service, immediate discussion with the admitting physician will be provided to educate and facilitate the necessary documentation.
- The CM will demonstrate the ability to discuss difficult/sensitive subjects with physicians in an articulate and professional manner.
- Confirm the diagnosis identified as the reason for admission.
- Request documentation to support admission.
- Confirm that the clinical symptoms/treatment, including severity of illness and intensity of service per Interqual guidelines for admission are met, as well as, payer guidelines for admission and continued stay. Maintains up to date knowledge of payer guidelines including Medicare, Medicaid, Commercial Insurance, Managed Care Plans, etc.
- Confirm that the defined level of care/status is appropriate for the identified treatment plan.
- Identifies readmissions and makes the appropriate referrals as needed to meet the needs of the patient. Documents Readmission Assessments appropriately and timely.
- Documents Avoidable Days appropriately and timely.
- Enters the Utilization Management review on all screened admissions.
- Continues to reassess observation cases and outpatient in a bed cases throughout the length of stay, with the assistance of the ED/Admissions case managers, for potential conversion or discharge.
- Enters the concurrent Utilization management reviews on all payer cases requiring clinical information. Clinical information is faxed or transmitted electronically as needed.
- Communicates to registration the need for inpatient authorizations.
- Communicates to the Director of Case Management, House Supervisor, CNO or CFO as needed when a patient does not meet admission screening guidelines or continued stay guidelines and patient is admitted or remains in-house.
- Supports cost containment efforts through resource management, reporting variances to department Director or Manager.
- Discharge Planning Responsibilities:
Proactively screens and assess patients assigned in order to determine discharge needs and establishes a viable discharge plan while collaborating with patients, families, and a multidisciplinary team.
- Consults and collaborates with a multidisciplinary team on complex cases.
- Provides consults and referrals for patients that may include: adoption, fetal demise, teen pregnancies (under 14 years of age), abused or neglected children, abused or neglected elderly, complex family issues, suicidal patients, patients with a terminal diagnosis and/or patients who are victims of domestic violence.
- Maintains knowledge of payer guidelines governing discharge planning; including Medicare, Medicaid, Commercial Insurance, Managed care, etc.
- Documents discharge plans in the patients chart and communicates the plan to all parties involved including patient, family, physician, nursing, etc.
- Actively participates in continuous quality improvement and is fiscally responsible when using charitable hospital resources.
- Case Manager follows all departmental and hospital safety policies, including identification and correction of environmental and practice safety issues.
- Develops self professionally and participates in hospital and departmental activities.
- Assists in the development, implementation and evaluation of policies, standards, educational services, and programs that support the CTMC mission.
- Represents the Case Management Department on interdisciplinary teams. These may include committees/meetings within the organization or out in the community.
- Demonstrates initiatives in developing, implementing and analyzing quality improvement strategies for the case management department.
- Initiates activities to enhance revenue and support cost reduction and containment activities.
- Rounds with the physician when appropriate or upon request.
- Performs other duties as assigned.
What you will need:
- Graduate from an accredited school of nursing
- Bachelor’s in Nursing
- Current license as an RN in the state of Texas.Five years related experience and/or training preferredExperience in case management preferred
- Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
- Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
- Effective communication among employees, and between employees, patients, visitors and supervisors is essential to ensure quality patient care and to avoid misunderstanding, errors and miscommunications which could have a detrimental effect on the health, safety and well-being of patients and co-workers. In addition to these communication and safety concerns, individuals in this position must be able to effectively review patient and related medical records, understand nurse and/or physician verbal and written instructions, read labels of medications, safety information, and hazardous chemicals. Therefore, to prevent misunderstandings, errors, and miscommunications in the provision of quality patient care and other job-related services, employees in this position are required to have the capability of fluently speaking, reading, and writing English.
- Ability to work with mathematical concepts such as probability and statistical inference. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.