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RN Case Manager II
Fairfax Medical Campus 608904 Full Time 3300 Gallows Road, Falls Church, VA, 22042, USApply
Job DescriptionActively participates in clinical performance improvement activities. Develops, implements, and evaluates patient care plans and progression throughout the continuum or disease state. Works collaboratively in communication with physicians, nursing and other members of the multi-disciplinary care team to effect timely and appropriate patient management. Provides discharge planning and continuity of care for assigned patients in the acute and post-acute setting. Understands pre-acute and post-acute resources. Provides coordination of services and acts as key liaison between patient, the patient's family and the interdisciplinary healthcare members. Uses clinical expertise or utilization management techniques to determine the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities. Responsible for timely regulatory compliance and facilitation of precertification and payer authorization processes, when indicated.
- Collects quality metrics data for specific performance and/or outcome indicators.
- Assists in the collection and reporting of resource and financial indicators including acute and post-acute case mix, LOS, cost per case, excess days, resource utilization, readmission rates, denials and appeals.
- Collects, analyzes and addresses variances from the plan of care/care path with physician and/or other members of the healthcare team.
- Uses concurrent variance data to drive practice changes and positively impact outcomes.
- Documents key clinical path variances and outcomes which relate to areas of direct responsibility (e.g., discharge planning, chronic disease planning).
- Uses pathway data in collaboration with other disciplines to ensure effective patient management concurrently.
- Ensures safe care to patients adhering to policies, procedures, and standards, within budgetary specifications, including time management, supply management, productivity, and accuracy of practice.
- Promotes individual professional growth and development by meeting requirements for mandatory/continuing education, skills competency, supports department-based goals which contribute to the success of the organization.
- Participates in the assessment of patient's clinical and psycho social needs through review of patient information, personal contact with patient/family, and interdisciplinary care team members.
- Communicates routinely with the patient, family, interdisciplinary care team members and other appropriate parties with regard to status of patient care plan and progress toward treatment goals, identification of concerns and/or problems, problem-solving and assisting with conflict resolution when necessary.
- Addresses/resolves system problems impeding diagnostic or treatment progress.
- Seeks consultation from appropriate disciplines/departments as required to expedite care and facilitate discharge.
- Ensures that all elements critical to the patient's care plan have been communicated to the patient/family and members of the healthcare team and are documented as necessary to assure continuity of care.
- Provides discharge planning and continuity of care for assigned patients in the acute and post-acute setting. Initiates and facilitates referrals to specialists, clinics, home health care, hospice, SNF, acute rehab, LTAC, TCM, medical equipment and supplies, as indicated.
- Collaborates with interdisciplinary care team, patient and family in the assessment and coordination of discharge planning needs, delivery of post-discharge planning needs, delivery of post-discharge services and transition of the patient from the hospital to the discharge setting, as well as ongoing care in the community.
- Documents relevant discharge planning and/or care management plan information in the medical record according to department standards, and/or care management plan.
- Collaborates/communicates with internal and external case managers. Understands pre-acute and post-acute resources.
- Work closely with the members of the patient's healthcare team to manage and coordinate all areas of the patient's care.
- Work holistically to ensure that care plans and discharge plans meet the physical, social, and emotional needs of patients.
- Provides educational resources and/or referrals to the patient and patient's family to address identified needs such as social or financial.
- Acts as patient's advocate to resolve barriers to care progression.
- Communicates with payers or required parties to ensure reimbursement certification for assigned patients.
- Discusses payer criteria and issues on a case-by-case basis with clinical staff and follows up to resolve problems with payors as needed.
- Applies approved clinical criteria to monitor appropriateness of admissions, continued stays or post-acute/ambulatory setting appropriateness and documents findings based on department standards.
- Identifies at-risk populations using approved screening tool and follows established reporting procedures.
- Monitors LOS and ancillary resource use, depending on inpatient stay or outpatient program criteria, on an ongoing basis and takes actions to achieve continuous improvement efficiencies in both areas.
- Refers cases and issues appropriately to resolve barriers to care progression.
- 2 years of experience in case management or clinical care.
- Bachelor's degree in Nursing.
- ACM, CCM, or MCG certified. BLS certified through the American Heart Association.
- Valid Virginia Registered Nurse (RN) License