The Care Manager performs Utilization Review, Discharge Planning and Case Coordination, mobilizing appropriate internal and external resources in order to achieve optimum value for the patient and reimbursement source.  Evaluates patient utilization to determine appropriateness of patient stays and assesses patient care quality.  The Case Manager is an active member of the patient care team, providing clinical expertise, problem identification and data collection for quality improvement initiatives. 

Licensure/Certification/Registry:

• Registered nurse currently licensed in the state of Illinois. BSN preferred.

Experience:

• Minimum of 2 years clinical acute care nursing experience required (additional long-term care experience preferred).

Other Knowledge/Skills/Abilities:

• Demonstrates ability to effectively communicate complex ideas and data and interact with all levels of professions.
• Demonstrates adaptability to changes in healthcare environment with proactive problem solving attitudes.
• Strong critical thinking skills and ability to integrate knowledge.
• Excellent communication, collaboration and organizational skills.
• Understanding of healthcare reimbursement mechanisms preferred.

1. Care Coordinator
• Responsible to direct and facilitate movement of medical services along the continuum of care working in collaboration with a multidisciplinary team to establish a plan of care that will provide medically appropriate, high quality, efficient care for the patient and secure certification with reimbursement services. Documents appropriately.
• Assess family dynamics and how they may impact patient outcomes. Educates patients/families and healthcare providers regarding utilization issues and discharge options. Collaboration with healthcare team to ensure discharge needs are assessed for patients of all ages and that an appropriate plan is developed/implemented in a timely manner.
• Monitors patient length of stay by conducting admission, concurrent and discharge screening reviews. Collaborates with physicians to ensure resource utilization remains within covered benefit entitlements and are appropriate in relationship to the patient’s clinical and psycho-social needs.
• Provides clinical consultation and education to physicians, multidisciplinary team and other healthcare professionals. Participates in quality improvement by identifying problems and/or opportunities for improvement in clinical outcomes, utilization of resources, concurrent data collection for potentially avoidable days, delays in services and quality improvement initiatives.

2. Utilization Management
• Review prospectively/concurrently/retrospectively all inpatients for appropriateness of admission, appropriate level of care, and determine appropriate length of stay based on established criteria. Interviews when case fails to meet criteria.
• Provides consultation to physicians/healthcare professionals to assist with criteria based decisions and assists with appeals process by providing timely input regarding case specific details and information.
• Communicates care management/utilization management activities with external review agencies within agreed upon time frame. Monitors patient length of stay and collaborates with physicians to ensure resource utilization remains within covered relationship to patient’s clinical and psychosocial needs.

3. Referrals/Transfers
• Assist in establishing definitive transfer plan or home care plan prior to discharge as needed, including appropriateness of the requested services. Transfers may include acute care hospital, rehab, swing bed or skilled nursing facilities.
• Interacts with patient/family caregiver to develop a plan to include identification of necessary resources to meet patient needs.
• Utilizes clinical skills to obtain authorization/certification of discharge plan by third party payors when necessary.
• Acts as an advocate in denial/appeal process for hospital and/or patients.
• Maintains knowledge of hospital utilization management plan, current Federal/State regulations as well as Third Party Payor requirements, and department/hospital policies and procedures.
• Promotes a collaborative team approach between physicians and all departments.
• Completes required annual safety/infection control education and at least 8 hours of additional continuing education.
• Promotes health and safety in the work environment.
• Actively participates in competency assessment process.

4. Performs other job related duties as assigned or as necessitated.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job. Incumbents may be requested to perform tasks other than those specifically presented in this description.